Incident Report – Environmental Health & Safety

Please fill out as much information as possible regarding the incident.

All items marked with a * are required.

Your Name * Required
First Last
Gender * Required
Date of Birth * Required
MM slash DD slash YYYY
EWU ID# * Required
Email * Required
Phone Number * Required
Campus/Mail Address * Required
Who are you reporting this incident for? * Required
- Self
- Someone else
- This incident did not involve a person
EWU Position * Required
Occupation/Job Title * Required
Work Schedule * Required

What are the typical days and times that you work/volunteer?
Department * Required
Please indicate your department or "NA" if you don't have a department.
Date of Hire * Required
When did you start at EWU?
Time Began Work * Required
What time did you begin working on the date of the incident?
Incident Type * Required
What happened?
Did the incident involve an injury or illness? * Required
- No
- Yes
Did the incident involve a death? * Required
- No
- Yes
Describe "other" * Required
Date of Incident * Required
MM slash DD slash YYYY
Time of Incident * Required

: Hours

Minutes

AM/PM AM/PM
Location of Incident * Required
Name of affected individual * Required
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 initial
Please enter the EWU ID# or middle initial/name of the affected individual.
EWU Position of affected individual * Required
Please indicate the EWU position of the affected individual.
Complete Description of Incident * Required
Please include a detailed description of what happened, attach photographs and sketches at the end of this form if available.
Activity Immediately Before Incident * Required
What was happening before the incident occurred?
Witnesses
Include phone number and address if possible.
Injury/Illness Location * Required
Side of Body Affected * Required
Treatment Given * Required
What type of medical treatment was given
Name of Person Who Provided Initial First Aid * Required
Transportation Provided * Required
How did the affected person leave the site of the incident?
Date of Treatment * Required
MM slash DD slash YYYY
Name of Physician, Hospital or Clinic * Required
What is the name of the Physician, Hospital or Clinic where medical treatment was provided?
Address of Physician, Hospital or Clinic
What 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 Country
Was the injured/ill person admitted to the hospital? * Required
- No
- Yes
- Unknown
Injury Activity * Required
Indicate the activity being performed when injury occurred.
Sport * Required
What sport was being played when the injury occured?
Describe "other" * Required
Nature of the Sport Activity * Required
Name of Chair/Instructor/RA/Supervisor * Required
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 * Required
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/Supervisor
Other Information
Is there any other information that would be helpful for investigating the incident or fixing any problems that caused or resulted from the incident?
Associated Files
Upload files associated with the incident here. Please do not upload HIPAA protected files, this website is not secure enough for those files. If you have HIPAA 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

Max. file size: 63 MB.
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 confirmation email you will receive when this form is submitted.
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Incident Report Number
Enter the incident report number from the incident report spreadsheet.
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Do we need the supervisor to fill out an Investigation form?
- No
- Yes
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L&I Claim Number
Enter the L&I claim number if there is one
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Police Report Number
Enter the police report number if there is one
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Notes
For keep track of stuff!