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Injury Report Form
Campus Safety #408.554.4444
SCU Campus Safety Reference Number
Report Submitted By
*
Incident Information
Date of Incident
*
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
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31
Year
Year
2019
2020
2021
2022
2023
Time of Accident
*
Hour
hour
1
2
3
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5
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9
10
11
12
:
Minute
minute
00
01
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59
am
pm
Event
*
Name of Injured Person
*
Preferred Gender
*
- Select -
Male
Female
Prefer Not to Identify
Other...
Preferred Gender Other...
Phone Number(s)
*
Type of Injury
*
Details of Accident and/or Injury
*
Was Medical attention desired and/or required?
*
- Select -
Yes
No
Other...
Was Medical attention desired and/or required? Other...
Witness/Good Samaritan
Witness/Good Samaritan Name
Telephone Number
Office Use
Who was called?
- None -
Campus Safety
911
Other...
Who was called? Other...
Follow Up
Date
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
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24
25
26
27
28
29
30
31
Year
Year
2019
2020
2021
2022
2023
Follow Up Details
Leave this field blank
:)
