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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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
Year
2017
2018
2019
2020
2021
Time of Accident
*
Hour
hour
1
2
3
4
5
6
7
8
9
10
11
12
:
Minute
minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
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
23
24
25
26
27
28
29
30
31
Year
Year
2017
2018
2019
2020
2021
Follow Up Details
:)
