Incident Report Top Please fill out as much information as possible regarding the incident. All items marked with a * are required. Your Name* First Last Gender*Please select from list belowFemaleMaleOtherDate of Birth* Date Format: MM slash DD slash YYYY EWU ID#*Email* Phone Number*Campus/Mail Address*Who are you reporting this incident for?*SelfSomeone elseThis incident did not involve a personEWU Position*Please select from list belowStudent (no EWU work position)FacultyExempt PersonnelClassified StaffStudent workerPart Time - not studentVolunteerOccupation/Job Title*Work Schedule*What are the typical days and times that you work/volunteer?Department*Please indicate your department or "NA" if you don't have a department.Date of Hire*When did you start at EWU?Time Began Work*What time did you begin working on the date of the incident?Incident Type*What happened?Please select from the list belowAbrasion/ScratchBite/StingBlood ReleaseBurnConcussionCrush/PinchCut/LacerationDental InjuryDermatitisDislocationElectric ShockEye InjuryFireFractureHazardous Contact/ReleaseHearing ImpairmentHerniaIllnessNeedle Stick/PunctureRepeated MotionSprain/StrainOtherDid the incident involve an injury or illness?*NoYesDid the incident involve a death?*NoYesDescribe "other"*Date of Incident* Date Format: MM slash DD slash YYYY Time of Incident* : HH MM AM PM Location of Incident*Name of affected individual*Who did the incident happen to? If the name is not known, please state "Unknown". If no individuals were affected, please enter "NA".Affected individual's EWU ID# or middle initialPlease enter the EWU ID# or middle initial/name of the affected individual.EWU Position of affected individual*Please indicate the EWU position of the affected individual.Please select from list belowStudent (no EWU work position)VisitorFacultyExempt PersonnelClassified StaffStudent workerPart Time - not studentVolunteerOtherUnknownComplete Description of Incident*Please include a detailed description of what happened, attach photographs and sketches at the end of this form if available.Activity Immediately Before Incident*What was happening before the incident occurred?WitnessesInclude phone number and address if possible.Injury/Illness Location*Please select the primarily affected areaAbdomen / InternalAnkle / Foot / ToesArm / Elbow / ShoulderBackChestEars / Eyes / NoseFace / HeadFinger / Hand / WristGroinHip / Knee / LegNeck / ThroatRespiratoryUnknownSide of Body Affected*Please select from belowBothLeftRightUnknownTreatment Given*What type of medical treatment was givenPlease select from list belowFirst Aid OnlyMedical Treatment ReceivedNo Treatment Necessary/Treatment RefusedUnknownName of Person Who Provided Initial First Aid*Transportation Provided*How did the affected person leave the site of the incident?No TransportationWalkedCarAmbulanceUnknownDate of Treatment* Date Format: MM slash DD slash YYYY Name of Physician, Hospital or Clinic*What is the name of the Physician, Hospital or Clinic where medical treatment was provided?Address of Physician, Hospital or ClinicWhat is the address of the Physician, Hospital, or Clinic where medical treatment was provided? Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Was the injured/ill person admitted to the hospital?*NoYesUnknownInjury Activity*Indicate the activity being performed when injury occurred.Please select from list belowAssigned Work DutyDrivingRunning/Walking on CampusSportsOtherUnknownSport*What sport was being played when the injury occured?Please select from list belowBaseball/SoftballBasketballClimbingFootballIce Skating/HockeySoccerSwimmingVolleyballWorking OutOtherUnknownDescribe "other"*Nature of the Sport Activity*Please select from belowClassCampus RecreationOtherName of Chair/Instructor/RA/Supervisor*If you are the chair, instructor, or supervisor, please include your name here. This is required for incident investigations. First Last Email of Chair/Instructor/RA/Supervisor*If you are the chair, instructor, or supervisor, please include your email here. This is required for incident investigations. Phone Number of Chair/Instructor/RA/SupervisorOther InformationIs there any other information that would be helpful for investigating the incident or fixing any problems that caused or resulted from the incident?Associated FilesUpload files associated with the incident here. Please do not upload HIPPA protected files, this website is not secure enough for those files. If you have HIPPA files they can be sent to EH&S by replying to the conformation email you receive after submission. The maximum file size is 8MB. Drop files here or If you were injured while working or volunteering with EWU it is strongly recommended that you seek medical attention to ensure your health and safety. If you choose not to seek medical attention for your injury, please fill out the Informed Refusal for Medical Evaluation. This form is used to acknowledge that you were advised to seek medical attention and you declined. Filling out this form will not prevent you from seeking medical attention for this injury in the future. Save a copy of the Informed Refusal for Medical Evaluation and have your supervisor sign it. Send it to EH&S by replying to the conformation email you will receive when this form is submitted.Incident Report NumberEnter the incident report number from the incident report spreadsheet.Do we need the supervisor to fill out an Investigation form?NoYesL&I Claim NumberEnter the L&I claim number if there is onePolice Report NumberEnter the police report number if there is oneNotesFor keep track of stuff!