INJURY REPORT

YOU ARE REQUIRED TO FILL OUT TWO FORMS: THIS FORM AND ONE FROM THE UNIVERSITY. THE LINK TO THE UNIVERSITY FORM IS: https://incident.byu.edu/forms/injury/

Please fill out this form immediately following a personal injury to you or one of your crew on your MAL approved project. If there are multiple incidents, please fill out a separate form for each.

Please note: this form is for reporting purposes only. As a reminder, BYU policy states that students are required to maintain health insurance through the duration of their enrollment and experience at BYU. Studnet's personal health insurance and other forms of accident and life insurances are primary in all cases, as a result of their involvement in class activities, (except for cases arising from the sole negligence, intentional act or omission of BYU).

Person Reporting - The person filling out this form.*

First NameLast Name

Person Reporting Phone*

Area CodePhone Number

Person Reporting Email*

example@example.com

Date of Incident*

Date

Time of Incident*

:HourMinutesAM/PM Option

Name of Injured Person*

First NameLast Name

Address of Injured Person*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone of Injured Person*

Area CodePhone Number

Age of Injured Person*

Birth Date of Injured Person

Date

Status of Person at Time of Injury*

StudentStaff (off clock)Visitor

How Injury Happened - Include the following information: background information, description of event(s), detailed description of Injury sustained, estimated costs or associated hospital/doctor visits & costs.*

Witnesses - Please list one to three witnesses and their contact information.*

Activity Supervisor (Producer / Director / Professor)*

First NameLast Name

Activity Supervisor Phone*

Area CodePhone Number

Activity Supervisor Email*

example@example.com