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 student Minor/Child Visitor
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: *

Month Day Year
Date Hour Minutes AM/PM Option
Location of Incident: *
Event:
If applicable
Describe Details of the Incident: *
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Was First Aid Administered?

Yes No Non-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:

Month Day 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: