Report • CampusOptics

Reporter Info

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First Name* Required

Last Name* Required

Location

Name* Required

Floor or Area

Additional Location Details

Exact Location

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No Location Set

Latitude

Longitude

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Name:

Witnesses

Is the person an employee of the university?

Was there any additional called made?

Yes

If an additional call(s) was/were made, who was it to?

Video of incident?

If yes to Video, please describe location of possible camera

What description best defines the incident?

Slip

Slip with a Fall

Trip

Trip with a Fall

Fall

If a slip, please select type that best describes the incident.

Wet (e.g., water, mud, grease, oil, food, blood, etc.)

Dry product spills (e.g., powder, dust, wood chips, granules, plastic wraps)

Weather hazards (e.g.,rain, ice, snow)

Loose, unanchored mats and rugs

Concrete, ceramic tile, or marble floors

Newly waxed floors

Sloped or uneven walking surfaces

Wet, muddy, greasy shoes

Ramps or planks without skid- or slip-resistant surfaces

Metal surfaces

Climbing ladder

If a slip that results in a fall, please select type that best describes the incident.

Wet (e.g., water, mud, grease, oil, food, blood, etc.)

Dry product spills (e.g., powder, dust, wood chips, granules, plastic wraps)

Weather hazards (e.g.,rain, ice, snow)

Loose, unanchored mats and rugs

Concrete, ceramic tile, or marble floors

Newly waxed floors

Sloped or uneven walking surfaces

Wet, muddy, greasy shoes

Ramps or planks without skid- or slip-resistant surfaces

Metal surfaces

Climbing ladder

If a trip, please select type that best describes the incident.

Clutter on the floor

Obstructed view

Poor lighting

Misshapen, wrinkled carpets or mat

Uncovered cables, wires, hoses, and extension cord

Open drawers, cabinets, doors, etc.

Uneven walkways

Unmarked steps or ramps

Missing floor tiles and bricks

Damaged steps

Irregular, improper, or non-uniform steps

A trip that results in a fall, please select type that best describes the incident.

Clutter on the floor

Obstructed view

Poor lighting

Misshapen, wrinkled carpets or mat

Uncovered cables, wires, hoses, and extension cord

Open drawers, cabinets, doors, etc.

Uneven walkways

Unmarked steps or ramps

Missing floor tiles and bricks

Damaged steps

Irregular, improper, or non-uniform steps

If a fall was selected

Weak or damaged ladders

Ledges without proper railing

Carrying heavy objects

Failure to use guardrail or handrail

Unprotected edges

Unsafely positioned ladder

Misused fall protection

Did the Slip, Trip, or Fall cause an injury?

If yes to first aid

Address and Report

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.