Non-Employee Incident Report Form – Draft – Division of Business Services

Submitter's Information

Your Name*

First Last

Today's Date*

School/College/Division and Department*

UDDS Code

Please provide your 7-Digit UDDS Code: (i.e., A850000)

Your UW-Madison Email*

NOTE: For confidentiality purposes, please use your @wisc.edu email only

Your Phone Number*

Injured Individual/Property Owner

Name*

First Last

Age*

Please provide a phone number and email address if available

Phone Number

Email

Address*

Street Address Address Line 2 City State ZIP Code

Is this person requesting the Office of Risk Management contact them regarding the incident?*

Yes

No

Date of Incident*

Time of Incident*

If time is not known, please estimate to the nearest hour.

Hour

:

Minute

Affiliation with UW-Madison*

(e.g., student, parent, visitor, contractor/vendor, etc.)

Exact location of incident*

(e.g. Address, lot #, building name/number, specific location within building, class name/id)

Full description of the incident and cause, if known. Include descriptive details of the incident, comments, observations, contributing factors, etc.:*

Were witnesses present?*

Witness Information

Click the "+" symbol to add additional witnesses

Name

Phone number

Email

Non-Employee Incident Report Form – Draft

Submitter's Information

Injured Individual/Property Owner

Injury Information

Property Damage Information