Non-Employee Incident Report Form Step 1 of 4 25% Submitter's InformationYour Name* First Last Today's Date* MM slash DD slash YYYY School/College/Division and Department* UDDS CodePlease 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 OwnerName* First Last Age* Please provide a phone number and email address if availablePhone NumberEmail Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this person requesting the Office of Risk Management contact them regarding the incident?* Yes No Date of Incident* MM slash DD slash YYYY Time of Incident*If time is not known, please estimate to the nearest hour. Hour : Minute AM PM 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.:* Was there an injury reported?* Yes No Was property damage reported?* Yes No You must either report the property damage and/or the injury to complete this form.Injury InformationExtent of injury, describe exact injury and body part(s) impacted:*Describe the emergency procedures employed*(first aid, ambulance/911 called, etc.)Did the individual refuse treatment?* Yes No Reason for refusal of treatment* Did injuries require medical care beyond first aid?* Yes No Facility name and location where individual was taken to*Were Police or 911 called?* Yes No Who was the responding agency?*(i.e., UW Police, Madison Fire Dept., etc.) Police Case Number Property Damage InformationProvide a detailed description of property damages and estimated cost.* Were witnesses present?*YesNoWitness InformationClick the "+" symbol to add additional witnessesNamePhone numberEmail Add Remove *If you are having difficulty completing this online form, please contact risk management at email@example.com.