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Incident Report Form

Please report any incident whereby you and/or someone else is injured physically or emotionally, or damage occurred to Bellevue University property or to your personal property on Bellevue University's premises. Please file this report immediately after the incident. Please print upon completion.

INFORMATION ON INJURED PERSON OR OWNER OF DAMAGED PROPERTY
Full Name:
Address:
Work Phone:
Home Phone:
Cell Phone:

	Male Female
	Employee Student Other


INFORMATION ON THE INCIDENT
Date of the Incident (mm/dd/yyyy):
Time of the Incident:
Exact Location of the Incident:
Weather Conditions (if applicable):

Description of Incident:

Please Describe Nature of Injury or Property Damage:


Witness Name:
Witness Telephone Number:

Witness Name:
Witness Telephone Number:


ADDITIONAL INFORMATION
Medical Treatment?	Yes No

Type of Medical Treatment:	First Aid Emergency Room
	Physician Hospital
Treating Physician's Name:
Comments from Visit:


Incident Reported to Outside Agency?	Yes No

Outside Agency Notified:	Police Fire Department
	Other:
Police/Fire Station Address:
Name of Officer/Fire Investigator in Charge:
Phone Number of Officer/Fire Investigator in Charge:




Your Initials:
Your Supervisor's Name (if applicable):
Email Address (required to receive a copy of this report):


Click Here to print your completed form. Another copy will be emailed to the address you provided above.