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	Country

Information About This Incident

Date Occurred: *

Date

at

Hour Minutes AM/PM Option Date Picker Icon

Location of Incident: *

Event:

If applicable

Describe Details of the Incident: *

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:

Date Date Picker Icon