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Visitor Incident Report

Visitors, please fill out an incident report if you have a problem while visiting our campus or at EWU sponsored events.

Please do not use this form to report: Graffiti, Harassment, Theft, or Vandalism. Call 911 or contact EWU Campus Police at 509.359.7676

Please include as much information as possible in your incident report!

Your Name * Required
Sex * Required
- Female
- Male
- Other
Email * Required
Phone Number * Required
Date of Birth * Required
MM slash DD slash YYYY
Incident Type * Required
What happened?
Was there an injury associated with this incident? * 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 state "NA".
EWU Position of affected individual * Required
Please indicate the relationship between the affected individual and EWU.
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 were you doing, or what was happening, immediately before the incident occurred?
Witnesses
Include phone number and address if possible.
Immediate Cause of Incident * Required
What caused the incident?
Describe "other" * Required
Root Cause of Incident * Required
Why did the incident occur?
Describe "other" * Required
Injury/Illness Location * Required
Please select the primarily affected area.
Body Side Affected
- Both
- Right
- Left
Medical Treatment * 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?
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
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 Sports Activity * Required
Environmental Factors * Required
Did any environmental factors cause or contribute to the incident?
Describe "other"
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 any 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

Max. file size: 63 MB.
Hidden
Incident Report Number
Put the incident report number from the spreadsheet here.
Hidden
Does this report require follow-up?
- No
- Yes
Hidden
Has reporter been contacted?
- No
- Yes
Hidden
Make notes of follow-up here.
Write up a brief description of the follow-up with the reporter.

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