Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Last Name of Injured* Required

First Name of Injured* Required

Parent or guardian name and phone number if injured is a minor

Is the injured person a student or visitor?* Required

Date of Incident* Required

Time of Incident

Date of Birth

Phone

Describe EXACTLY what happened, include timeline of event and OBJECT or SUBSATNCE that caused harm:* Required

If other, please describe:

If other, please describe

Was the injured person wearing Personal Protective Equipment? (please specify)

Was first aid administered?

Was medical treatment received?

Treatment location:

Signature* Required

The person signing is the:* Required

Student

Visitor

Parent or Guardian

WVU Representative

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