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For a printable version of this form click here
INCIDENT REPORT
Injuries or Property Damage to Others
Instructions: Use this form to report injuries or property damage sustained by visitors, students, or the general public alleged to have been caused by the University or occurring on University property during a University activity or event (do not use for auto accidents or employee injuries). Complete all sections, retain a copy, and mail, email or fax to:
Ed Nobles, Risk Manager, University of Maine System, 16 Central Street, Bangor, ME 04401
Email: enobles@maine.edu Fax: 207-947-7556 Phone: 207-973-3331
Details of Incident:
Date of Incident:__________________
Time:____________________ ___a.m. ___p.m.
Weather Conditions:_____________________
Location of Incident (campus/building name/off-site location):_____________________
Street Address:_____________________________________
City:_____________________________
State:______________
Zip:__________
Did the police investigate the incident and make a report? ___Yes ___No
If yes, which police dept.?_____________________________
Description of what happened and any action taken (attach additional sheets if needed):
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Injured Person(s) (if more than one person injured, attach additional sheets)
Name:____________________________________
Phone:____________________________________
Email:____________________________________
Address:__________________________________
City:_____________________
State:_____________
Zip:______________
___Visitor ___Student ___Other (describe) _____________________
Age:___________
Description of
Injury:______________________________________________________
________________________________________________________________________
Medical Assistance Provided? ___Yes ___No
If yes, by whom?__________________________________
Property Damage (if available, attach appraisals, estimates or receipts)
Property Damaged:_____________________________________________________
Extent of Damage (include
estimate):__________________________________________
________________________________________________________________________
Owner Name:_____________________________
Owner Phone:______________________
Email:____________________________
Address:________________________________________________
City:_________________________
State:________________
Zip:_________________
Witnesses:
Name:______________________________
Phone:______________________________
Email:____________________________
Address:________________________________________________
City:_________________________
State:________________
Zip:_________________
Name:______________________________
Phone:______________________________
Email:____________________________
Address:________________________________________________
City:_________________________
State:________________
Zip:_________________
Name:______________________________
Phone:______________________________
Email:____________________________
Address:________________________________________________
City:_________________________
State:________________
Zip:_________________
Person Completing Report (if other than campus Risk Management Administrator)
Name:__________________________________
Date of Report:_______________________
Phone:_________________________
Campus/Dept. (if applicable):____________________________
___ Visitor ___ Student ___ Other (describe)___________________________
Campus Information (to be completed by campus Risk
Management Administrator)
Name:_____________________________________
Campus:________________________
Phone:__________________________
Was Incident investigated by campus? ___Yes ___No
If yes, attach notes on investigation, including any photographs.
Date Form Completed:________________________
Is this report for notification purposes only? ___Yes ___No
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