Date injury occurred: __________________________________   Time occurred: _________________________________________________

Personal contact information of person injured:

Name: __________________________________

Address: ________________________________

Phone: _________________________________

E-Mail: _________________________________

Location of incident: ___________________________________________________________________________________________________

Describe what happened: _______________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Describe apparent injury: _______________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Was an ambulance or police called?          YES           NO

Name/Address/Phone Number of any witnesses (if known):

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________

Form Completed by: ____________________________________   Date: _________________________________________________________

Complete immediately and email your regional liaison or mail to: Your Regional Liaison

Dick & Sandy Dauch Alumni Center 403 West Wood Street

West Lafayette, IN 47907