Submit an New Incident Report

Step 2: Congratulations, this is the final step for workplace incidents. Please complete the information below to submit the incident report which will conclude the reporting process. Once received, EH&S will review the incident report and notify you with any questions.


Upon completion, you will receive a summary email with additional instructions to view your previous incident reports.

Please enter the SFR reference number from your SFR submission as it appears (e.g. SFR-XXX).


If you have not yet submitted an SFR for this incident, please visit the EH&S website to submit a new SFR. You can use the following link to look-up an existing SFR that you previously submitted.

Find My SFR Number

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As you have indicated that you are submitting this report on behalf of another supervisor, please enter your CSUSB e-mail here.

Please enter the name of the supervisor for the involved employee you are reporting for.

Please enter the CSUSB email for the supervisor you are reporting for.

Part I: Employee Data (Injured Party)

Please complete the following information regarding the injured party.

Please include the Coyote ID of the injured party.

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Part II: Incident Information

Please list the date of injury. This may be different than the date you became aware of the injury and should match the SFR submission.

Please select all that apply.

Please briefly describe the nature of the incident. (e.g. employee fell off a ladder while repairing lights.)

Please provide the location where the incident occurred. Please be as specific as possible.

Please select all that apply

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Treatment Provided*

Please indicate where the employee received treatment.

Please select below which statements are applicable to this report.

Please paste the employee (Injured party) statement here.

Please include the full name of the witness (if available)

Please provide the witness's best contact number.

Phone

Please include the witness' email if available. CSUSB Email is preferred.

Please paste the witness statements below.

Please list any supervisor observations or findings if applicable.

Part III: Identifying the Root Cause

Please select any applicable direct causes from the list below.

Please select any applicable indirect causes from the list below.

Please select any applicable basic causes from the list below.

Part IV: Action Items

Use the area below to capture any action items that are needed to prevent reoccurrence of this injury.

Action Items*

How many action items do you have related to this incident? Specific action item details can be added below.

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Please attach any supporting items such as photos, statements, action plans, procedures, etc.

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