Accident Report Form

Information about Injured Person

Legal Name*

First Last

Mobile Phone*

University Affiliation*

Student
Employee
Visitor/Guest
Vendor/Contractor

Provide name of supervising company and project worked while injured.

Supervisor's Name*

First Last

Shift Worked*

Local Address*

Street Address Address Line 2 City State ZIP Code

Home Address (if different)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Information about the Incident

Date*

Time*

:

Location of Accident*

Please provide street address or closest landmark, when possible.

Accident Description*

Describe what happened, how it happened, factors leading to the event, etc. Be as specific as possible. If a University vehicle was involved, please include the license plate number.

Photo Upload

Drop files here or

Max. file size: 49 MB.

Please attach photos of vehicle or property damage, if pertinent.

Description of Injury*

Please describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).

Witness Information

Provide names, phone numbers and email addresses of witnesses, if present.

Police report number

Complete only if police were notified (�þ�� Safety & Police, Elon Town Police, Burlington Police, etc.)

Did you seek medical treatment?*

Yes
No
Refused

What treatment facility did you use?*

Did you return to work after receiving medical treatment?

Yes
Yes, with restrictions
No

Describe restrictions

Employees must provide return to work restrictions to supervisor and Risk Management and Insurance. Employees must be approved to return before resuming job duties.

Reporter Information

Individual Submitting Report*

First Last

Signature*

Date Report Completed*

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Email

This field is for validation purposes and should be left unchanged.

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