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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