Incident Report • CampusOptics

Call 9-911 for: loss of consciousness, stroke, seizures, heart attack, electric shock, allergic reaction or bleeding and Call EHS @ 304-293-3792 to report.

REPORT ALL INCIDENTS WITHIN 24 HOURS

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Section One: Demographic and Incident Details

Last Name of Injured* Required

First Name of Injured* Required

Middle Initial of Injured

WVU ID* Required

Gender

Date of Birth* Required

Age

Date/Time incident OCCURED* Required

What DATE did the injured worker First Notify the supervisor/employer?* Required

What TIME did the injured worker First Notify the supervisor/employer? (eg. 12:30PM))* Required

Specific Time of Workday

Employment Category

Department

Job Title

Status

Length of Employment (years)

Time in occupation when incident occurred (years)

Describe Exactly what happened, Include timeline of event and OBJECT or SUBSTANCE that caused harm:* Required

Body Part Location* Required

Bilateral
Left
Lower
Middle
Not applicable
Right
Upper

Add Supporting Documents

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

Employee Injury/Incident Report

Reporter Info

Location

Section One: Demographic and Incident Details

Section Two: Treatment and Additional Information

Add Supporting Documents