Accidental Injury Report

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INSTRUCTIONS: Complete this report for ANY non-work related injury that occurred on-campus.

This form may be completed by the UCB staff to who the injury was reported or the injured individual, and will be received by Risk Services and EH&S.

If this form cannot be accessed, make a copy of this document and return the completed form immediately to risk@berkeley.edu and ehs@berkeley.edu; or mail to the Office of Risk Service, 2111 Bancroft Way, Berkeley, CA 94720.

Email *

Name of Injured Person *

Email contact for Injured Person

Phone number for Injured Person

Address for Injured Person

Age

Gender

Male

Female

Prefer not to say

Other:

Clear selection

Status

Student

Visitor

Other:

Clear selection

Injury date

YYYY

Injury time

Time

Person in charge of area or activity where injured occurred

Was UCPD called? *

Yes

Refused to call

Was medical treatment provided? *

No treatment provided

Called 911

Tang Center (University Health Services)

Alta Bates Medical Center

Other Healthcare Facility

Did not seek treatment from a healthcare provider

Treatment by others (e.g. bystander administered first aid, Naloxone, Epi Pen, etc.)

Other:

Required

If Other Healthcare Facility was selected, what was the name and location of the facility?

Injury location - where did the incident happen? Include details such as building name, floor, room number, and so forth. If the injury occurred outdoors, provide location description to help identify the area. *

Injury description - include type of injury and parts of the body affected. For example, cut on right thumb; sprained left ankle, etc. *

Describe how the injury occurred. Include circumstances under which it occurred, environmental conditions (e.g. weather), the built-environment, tools or equipment in use, etc. that might have been a factor. *

Were there any other people injured? Provide names and contact information if available.

Were there any witnesses to the injury? Provide names and contact information if available.

Did the injury involve any of the following?

Lab work

Shop work

Building conditions (e.g. floors, walls, ceilings, stairs, equipment, indoor air quality, etc.)

Outdoor Environment (including landscaping, trees, walkways, stairs, etc.)

Road or vehicles (including cars, trucks, scooters, e-bikes, e-scooters, e-skateboards etc.)

Participation in a sport

Other:

Name of reporting department

Name of person submitting this form *

Email contact for person submitting this form *

Phone number for person submitting this form

Campus address of person submitting this form *

Date of form submission *

YYYY

(For UCB EH&S only): What condition requires correction to prevent further injuries?

(For UCB EH&S only): Date that responsible campus unit was notified of condition to correct.

YYYY

(For UCB EH&S only): Date when correction was field-verified as completed.

YYYY

A copy of your responses will be emailed to the address you provided.

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