Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Injured Employee Name

Home Address

Home Phone/Cell Number

Department

Job Title

Work Schedule (hours)

Work Schedule (days of the week)

Start Time

End Time

Supervisor

Date of Injury

Location of accident

Time of Injury

What did you hurt?

What were you doing?

What led to the injury?

Witnesses

Did you receive medical treatment?

Where did you receive medical treatment?

Address of treatment facility

Did you lose any work time because of this injury?

List work time lost

Job restrictions?

Explain job restrictions

Another job affected by this injury?

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