Incident Report • CampusOptics

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Exposed Individual

Name

Sex

Date of Birth

Home Phone

Cell Phone

Work Phone

Address

City

State

Zip

Select One

If Employee, indicate department. If Student, indicate program where enrolled.

Source Individual

Name

Home Phone

Other

Address

City

State

Zip

Incident Details

Occurred At

Time incident was reported

Name and title of person initially notified

Did the accident/exposure result in any of the following? (check all that apply)

Percutaneous exposure (break in skin that caused bleeding)

Mucous membrane contact (eyes, nose, mouth)

Abraded skin, chapped skin, dermatitis

Other

If Other, Please Describe

Did the incident involve exposure to potentially infectious materials (blood, saliva, body fluids, contaminated solutions)?

If Yes, please describe

Describe precisely how the incident occurred

Describe what was done immediately after the incident.

Describe how this incident could have been prevented

Signature of Person making report

Signature of Supervisor/Witness

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.