Office of Engineering Safety

Engineering Safety Incident Report form

Please fill out the following form to report incidenct in Engineering Buildings and facilities. This is one of the fastest ways to get a written report through to the Safety Office.

(Training on "Incident Investigation and Analysis" available here )

Training on "Incident Notification and Reporting " available here

(Please make sure to fill all the datafields. Enter N/A for fields not applicable)

Current Date & Time:
Date & Time of incident:
Location where Incident Occurred:	Building Name Building Number Room Number Department/Center
Reported by:
Contact phone number:
Contact email:
Was anyone Injured:
TWCC "First Report of Injury & Illness" filed:
Degree of Injury:
Name of Person affected:
Victim's Employment Status:
Responsible PI/Faculty:
Employee's supervisor is:
Lost time:
Departmental Investigation:
Category of incident:
Description of incident:
Contributing factors:
Action Taken:
Recommended action:
Notes/Comments: