Non-Employee Incident Report Form "*" indicates required fields 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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 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.