CAMPUS ALERT

Bellevue University Tops U.S. News Rankings

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:

Notes:

 
 

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.

 

 

Thanks for your interest in Bellevue University.

When you click the submit button below, our staff will contact you within 48 hours to get you the information you need and answer any questions.

Yes No