Environmental Health & Safety Incident Report Form


This form should be used to report any incident, injury, illness, hazardous material spill, fire, property damage, alarm activation, near miss, or unsafe condition. 

Report Type (required)
Your Status (required)
If you are a College employee, please list supervisor:

Please be specific. Include the name of the campus building, room number, or an accurate description of campus location if the incident occurred outdoors. If the incident occurred off-campus, include the address.

Describe the incident. What happened? How did it happen? Please be as specific as possible.

Injury Information
Was anyone injured? (required)

If there were injuries, please identify the injured person(s) and describe their injury/injuries.

Was medical treatment provided? (required)
Type of Treatment Provided (required)
Witnesses to the Incident

NOTE: THIS REPORT DOES NOT CONSTITUTE AN ADMISSION OF LIABILITY BY WESTMINSTER COLLEGE. 

If you have any questions, please contact:
Bri Buckley
Director of Campus Safety
801.832.2529