Notice of Third-Party Incident

Instructions:

Instructions: This form should be completed by a University department witness or representative within 24 hours of an incident or injury to a third party on UO property or at a University of Oregon sponsored event. This form is for internal use only and is not intended to be used for filing a claim.

Third Party Information

Third party's Name:*

Current residential address:

3rd party's email address:

3rd party's phone:

Incident Information

Date Incident Occurred*

Time Incident Occurred (please indicate A.M/P.M)*

Name of event/activity:

Location of incident (building, room, specific location):

Description of incident (briefly describe what occurred below and contributing factors):*

Was there an injury?

Select or enter value

If yes, reported injured body part:

Was medical care provided?

Select or enter value

If yes, by whom?

Transported by ambulance?

Select or enter value

If yes, to which facility?

Responders Information

Did the UO Police Department respond?

Select or enter value

If yes, UOPD employee name:

Did a security crowd control individual respond (e.g. CMS)?

Select or enter value

If yes, name of individual(s):

Names of university employees responding or at the scene:

Was a Contractor or other outside party involved?

Select or enter value

If yes, list name(s) and contact information if possible:

UO Department Witness or Representative Information:

UO affiliate logging this incident (please print name):*

UO affiliate's email:*

Department name:*

Date of this report:*

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