Report • CampusOptics

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Additional Location Details

Exact Location

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Basic Information

TSU Police Report #

DOB

T number #

Occurred At

Gender

Address

City

State

Zip

Major

Secondary Phone Number

Incident Information

Did the student remain on campus?

Does the student have TSU insurance?

Was medical care declined on the date of injury?

Was the student taken by ambulance to the emergency room?

If yes, to what hospital?

What was the exact location of the accident (building name, stairs, dock, floor, room #):

What was the student doing just before the incident occurred? Describe the activity, as well as the tools, equipment or material the employee was using. Be specific. Attach additional pages if necessary.

Briefly describe exactly what caused the injury:

What areas of the student's body were injured? Be more specific than hurt, pain or sore and include right or left to indicate the exact location.

If Miscellaneous, please describe

What object or substance directly harmed the student? Examples: concrete floor, saw, acid, desk, chair.

When did you report your injury?

Name of person you reported injury to:

Title of person you reported injury to:

Phone Number of person you reported injury to:

List name and phone number of all known witnesses

By affixing my signature, I attest that all information on this form is accurate and true.

Signature Date

Printed name of person completing this form (if other than injured employee): By affixing my signature, I attest that all information on this form is accurate and true.

Add Supporting Documents

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