Incident Report • CampusOptics

For reporting Lab/Shop incidents that occur in a college instructional setting, please use one of the following methods:

-If you have a scanned copy of a paper Incident Report you can upload it to the documents section at the bottom of this form.

-If you are Reporting an incident digitally, please use the form below.

Reporter Info

Email Address* 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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Lab/shop incident form

Date of Incident

If occurred during Lab/Shop class give class name and Section Number

Location of Incident (Building and Room Number)

If occurred during Lab/Shop class provide Name of Instructor/Demonstrator.

Type of incident:

Student Injury/Incident/Illness

Full Name

Home Address

Campus Address

Choose current Status

If you are an Employee; please select the option that best fits your role.

Gender

Date of Birth

Phone Number (personal)

Phone Number (Campus/Office) if applicable.

Event in which the incident occurred.

If occured during Class (Shop or Lab) provide section name and number.

If occurred during Lab/Shop class provide the name of the instructor/demonstrator.

Describe to the best of your ability what happened, how happened, any factors leading to the event, and any substances or objects involved. Be as specific as possible.

Were there any witnesses. (Yes or No), if yes, provided their names and contact information.

Was there an injury due to the incident? If so, describe the injury, and any other information known about the injury.

Was there any medical treatment provided?

If medical treatment was provided describe the type of treatment performed. (First Aid kit, GCU Health center, Poison Control, Emergency room visit, etc.)

Was 911 called?

Reporters' information; Please provide your name and title

Add Supporting Documents

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