Accident/Incident Report
**If you complete this form, you MUST call Risk Management to inform them of the details behind the accident/incident. Risk Management will help you to determine if other campus partners or emergency contacts need to be notified.**

Form will be automatically sent to:
 
ACU Human Resources
Office: 325-674-2359 / Email: humanresources@acu.edu

&

ACU Risk Management
Office: 325-674-6142 or Cell: 325-232-1741 / Email: risk@acu.edu
Sign in to Google to save your progress. Learn more
Email *
CONTACT INFORMATION
Category *
Name *
Date of Birth *
Address *
Daytime Phone *
Mobile Phone *
City / State / Zip Code *
Employee/Student ACU ID # *
SUPERVISOR INFORMATION
Supervisor's Name *
Supervisor's Phone # *
ACCIDENT INFORMATION
Date *
MM
/
DD
/
YYYY
Time *
Time
:
911 called *
Police Report *
Photos Taken: *
If so, photos were taken by:
(Name & Phone #)
Location of Accident: *
Description of Accident: *
Description of any Injury: *
Description of any Property Damage: *
MEDICAL INFORMATION
Taken to Emergency Clinic *
Taken to Hospital *
Treatment Refused *
Taken by EMS *
Taken by Individual:
(Name and Phone #)
WITNESS INFORMATION
Name & Phone #
Name & Phone #
Name & Phone #
Provide any futher information or concerns
Completed by: *
(Name)
Today's Date
MM
/
DD
/
YYYY
Texas Worker's Compensation law allows investigation of each on-the-job accident, injury, or illness. Representatives of the ACU Risk Management or the university insurance carrier may contact you, witnesses to the accident, or the injured employee as part of this investigation.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of myACU. Report Abuse
Google Forms