Non-Employee Incident Report Form

Submitter's Information
Your Name*
First Last
Today's Date*
Date Format: MM slash DD slash YYYY
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*
Date Format: MM slash DD slash YYYY
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

Submitter's Information

Name	Phone number	Email