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You are here: Home / Incident Reporting / Incident Report

Incident Report

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Please fill out as much information as possible regarding the incident.

All items marked with a * are required.

  • MM slash DD slash YYYY
  • What are the typical days and times that you work/volunteer?
  • Please indicate your department or "NA" if you don't have a department.
  • When did you start at EWU?
  • What time did you begin working on the date of the incident?
  • What happened?
  • MM slash DD slash YYYY
  • :
  • Who did the incident happen to? If the name is not known, please state "Unknown". If no individuals were affected, please enter "NA".
  • Please enter the EWU ID# or middle initial/name of the affected individual.
  • Please indicate the EWU position of the affected individual.
  • Please include a detailed description of what happened, attach photographs and sketches at the end of this form if available.
  • What was happening before the incident occurred?
  • Include phone number and address if possible.
  • What type of medical treatment was given
  • How did the affected person leave the site of the incident?
  • MM slash DD slash YYYY
  • What is the name of the Physician, Hospital or Clinic where medical treatment was provided?
  • What is the address of the Physician, Hospital, or Clinic where medical treatment was provided?
  • Indicate the activity being performed when injury occurred.
  • What sport was being played when the injury occured?
  • If you are the chair, instructor, or supervisor, please include your name here. This is required for incident investigations.
  • If you are the chair, instructor, or supervisor, please include your email here. This is required for incident investigations.
  • Is there any other information that would be helpful for investigating the incident or fixing any problems that caused or resulted from the incident?
  • Upload files associated with the incident here. Please do not upload HIPAA protected files, this website is not secure enough for those files. If you have HIPAA files they can be sent to EH&S by replying to the conformation email you receive after submission. The maximum file size is 8MB.
    Drop files here or
    Max. file size: 63 MB.
    • If you were injured while working or volunteering with EWU it is strongly recommended that you seek medical attention to ensure your health and safety.

      If you choose not to seek medical attention for your injury, please fill out the Informed Refusal for Medical Evaluation. This form is used to acknowledge that you were advised to seek medical attention and you declined.

      Filling out this form will not prevent you from seeking medical attention for this injury in the future.

      Save a copy of the Informed Refusal for Medical Evaluation and have your supervisor sign it. Send it to EH&S by replying to the confirmation email you will receive when this form is submitted.

    • Hidden
      Enter the incident report number from the incident report spreadsheet.
    • Hidden
    • Hidden
      Enter the L&I claim number if there is one
    • Hidden
      Enter the police report number if there is one
    • Hidden
      For keep track of stuff!

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