Incident/Accident Report

Incident/Accident Report

This form is to be used for third party injuries and/or property damage that occur on university owned locations (on or off campus). Injuries to employees or work experience students are reported using the Supervisor Accident Report.

All Incidents/Accidents must be reported to Boise State University Risk Management.

Incidents/Accidents must also be reported to the Department of Public Safety at (208)-426-6911.

Include any supporting documents such as photos, drawings, or reports.

Contact Risk Management for additional information or assistance at (208)-426-3636 or (208)-426-5955 or via email to rmi@boisestate.edu

Name of Reporting Person:*

Reporting Person's Phone Number:*

Phone

Reporting Persons Email:*

Date of Incident:*

Time of Incident:*

Incident Accident Type:*

Select

Name of Affected Person:

Affected Person's Phone:

Affected Person's Email:

Home Address:

Location Occurrence:*

Select

Campus Location:*

Select

Campus Outdoor Location, Describe:*

Off Campus Location:*

Select

Apartment Complex Name*

Apartment Complex Address:*

Off Campus- Other, description:*

Description of Incident:*

Severity of Injury:*

Select

Injury Description:*

Treatment Received:*

Property Damage Estimate:*

First and Last Name(s) of Witness(es):

If multiple witnesses, please attach a separate document with contact information.

Witness(es) Phone Number(s):

Phone

Date Boise State Univ. Notified:*

Department Point of Contact:

File Attachments

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Incident/Accident Type

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