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Non-Work Related Incident Report Form

What to do if there is an Emergency:

Call the Department of Public Safety at 508-793-2222 (on-campus) or  911 (off-campus) for immediate medical assistance or to report an emergency. They are the first point of contact for all Emergencys. 

Members of the Holy Cross Community, to include students, employee's, faculty, staff, volunteers, spectactors, guests, audience members, etc... who experience an incident or injury are asked to complete this form regardless of the severity of the incident, accident or injury, to ensure we have an opportunity to address concerns and evaluate if any additional  assistance that may be needed within 24 hours of an incident or accident. 

Please be as detailed as possible and understand that we may follow-up to gather additonal information. Responses are reviewed by the a member of the Risk Management team and routed to other Department partners and we will reach out to you as needed. 

Submissions by Holy Cross students reporting  general injuries, or resulting from participating in Club or Intramural sports, may be contacted by Health Services to gather additional information and for follow-up.   

Our contact information is: 
Risk Management and Compliance
Ellen Anderson
eanderson@holycross.edu
508-793-2520

We thank you for taking the time to complete this form. 

Injured on the job?

If you are a student-worker, employee, or volunteer that experienced an injury or incident on the job, please navigate to this form: Incident Report - Employee to report your accident.


Email *
Date of injury, incident or accident 
MM
/
DD
/
YYYY
Time of Injury or accident 
Time
:
Injured Parties Name & or reporters name if different (identify role and title ex. Riley Harper, injured, student;  Quinn Emerson, reporter, team captain)  
Contact information - email and phone number - both injured party and reporter
Your relationship to campus
Clear selection
Were emergency responders called?
If first responders were not called,  please explain why if this was a serious injury or emergency. 
Please list the name and/or department of any other campus representatives you may have already notified or reported this concern to ( Supervisor,  Facilities, coach, captain, health services, etc..)
Type of report
Clear selection
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