Report • CampusOptics

If this is an employee injury or illness, including bloodborne pathogen exposure, use the C-1 Notice of Injury process with NSHE Workers' Compensation instead of this form.

If the incident occurred off-campus, search for 'Off Campus Location' in the Location field and provide details in Additional Location Details.

Depending on the incident type, EHS may follow up with additional requests for information or forms.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Person Involved

Name of Person Involved in the Incident:* Required

Phone Number:* Required

Email:

Department (if applicable):

Status:* Required

Incident Details

Type of Incident:* Required

Incident Date and Time* Required

Description of Incident* Required

Was medical treatment sought or received?

Witness

Witness?

First Responders

Were there first responders (Police, Fire Department, etc.) at the scene?

Additional Notes/Comments

Is there anything else you'd like to add?

Add Supporting Documents

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