Non-Employee Incident Report

Non-Employee Incident Report
Complete this report for all incidents on University property or at an activity where a non-employee is, or could have been injured. The person completing the report must be a University employee involved with supervision of the location or activity where the incident occurred. Provide this form to EH&S by noon of the business day following the incident.
Who Was Involved?

FGCU studentMinor/ChildVisitor
Contact Information for Non-employee Involved in This Incident
Contact Name:*

First Name Last Name
Contact Phone Number:*

Area Code Phone # (digits only)
Contact Address

Street Address

Street Address Line 2

City State

Zip Code Country
Name of Minor/ Child's Legal Guardian:*

First Name Last Name
Phone Number of Guardian:*

Area Code Phone # (digits only)
Address of Guardian:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Information About This Incident
Date Occurred:*

MonthDay Year
DateHour Minutes AM/PM Option
Location of Incident:*
Event:
If applicable
Describe Details of the Incident:*
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Was First Aid Administered?

YesNoNon-Employee refused
If yes, by whom?
Was an Ambulance Called?

Yes. Non-employee accepted EMS care.Yes, but non-employee refused EMS care.No
Was Non-employee Taken to Medical Care?

Yes, by ambulance.Yes, by other transport.No.
If yes, where?
Is There a Police Report?

Yes, by FGCU Police.Yes, by other Police.No.
If yes, what is the report #?
If other, describe:
Witness #1 Name:

First Name Last Name
Witness #1 Phone Number:

Area Code Phone # (digits only)
Witness #2 Name:

First Name Last Name
Witness #2 Phone Number:

Area Code Phone # (digits only)
Report Submitted By:
Name:*

First Name Last Name
Department:*
Phone Number:*

Area Code Phone # (digits only)
Email:*
example@example.com
Date Submitted to EH&S:

MonthDay Year
Date
Should be Empty:

Non-Employee Incident Report

Contact Information for Non-employee Involved in This Incident

Information About This Incident

Report Submitted By: