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Accident and Incident Reporting Form

Accident and Incident Reporting Form

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Form to report auto accidents, injuries, lab incidents, and any damage to property.

Welcome to Duquesne University’s online Incident Report Form.

This form is for anyone who has been involved in an Incident while on Duquesne University property or while conducting business for the University that resulted in an injury or in damage to property. Please respond as thoroughly as possible. If you do not have the information requested, indicate N/A. Individuals without Duquesne University Multipass access will need a University representative to complete this form. Parkhurst employees need not use this form. Parkhurst employees should report all incidents to their supervisor.

A copy of this report will be emailed to the person involved or injured in the incident, and to the submitter of this form, if different.

To begin, select all Incident types that apply:

To begin, select all Incident types that apply: (required)

Auto Incident

Injury

Facilities Management Incident or Injury

Laboratory Incident or Injury

Property Damage *(unrelated to an automobile accident)

Other *(Example: Visitor or Contractor)

Person Involved or Injured in the Incident:

First Name:

Last Name:

Email:

Personal Phone Number:

Work Phone Number:

DUQ Affiliate Status:

Department:

Permanent Home Address:

Permanent Home Address Line 2:

City:

State:

Zip Code:

Is the injured person’s Supervisor aware of this incident?

Yes

Full name of injured person’s Supervisor:

Phone number of injured person’s Supervisor:

Email Address of injured person's Supervisor (Only enter @duq.edu address):

Date of Incident: (mm/dd/yyyy)

Time of Incident: (mm/dd/yyyy hh:mm AM/PM)

Location of Incident

(Include as much detail as possible. For example, street address, building, and/or room number)

Were the police notified?

Yes

DU Public Safety Police:

Yes

Name of Police Department and Contact Information:

Are you filling this out for yourself?

(That is, were you the person directly involved or injured in the Incident?)

Are you filling this out for yourself?

Yes

Your First Name:

Your Last Name:

Your Email:

Your Permanent Home Address:

Your Permanent Home Address Line 2:

Your City

Your State:

Your Zip Code:

Your Personal Phone Number:

Your Work Phone Number:

Were there any witnesses?

Someone who observed the incident

Were there any witnesses?

Yes

Witness full name, email and/or phone number:

Please provide the full name(s), email(s) and/or phone number(s) of any witness(es)

Street address of Incident and nearby landmarks:

This section should be filled out if a Duquesne University employee or student is involved in an automobile Incident while on University property, while driving a University Insured Vehicle, or while driving on University business.

Weather and road conditions (wet, icy, snow, slush, dry, etc.):

Describe the Incident as thoroughly as possible:

Vehicle Type:

Vehicle Make / Model:

Vehicle License Plate Number:

Is your vehicle drivable?

Yes

Was another party involved?

Yes

Involved party full name / email / phone number

Please list all individuals involved in the auto accident

Was another vehicle(s) involved?

Yes

Other vehicle make / model:

Please list the make and model of all the other vehicles involved in the auto accident.

Other vehicle license plate(s):

Other vehicle auto insurance:

Other vehicle description of damages:

Did the accident result in any property damage other than to the vehicles involved?

Yes

Please provide a description of the property damaged from the incident (Auto):

This section should be filled out if an Incident resulted in personal property damage or in damage to Duquesne University property.

Damages to vehicles as a result of automobile Incidents do not apply here and should be described in the Auto Incident section instead.

Did the Incident result in any physical injuries to you/the subject of this Incident report?

Yes

Injury Description: (Auto)

Describe as thoroughly as possible the events leading up to and during the injury. Include the names of any machines, tools, parts, objects, materials, chemicals, and all other important details:

Please describe the injury: (Auto)

Injured arm (Auto)

Select all that apply

Injured arm (Auto)

Left

Right

Injured leg (Auto)

Select all that apply

Injured leg (Auto)

Left

Right

Injured part of head (Auto)

Select all that apply

Injured part of head (Auto)

Front

Back

Left

Right

Injured eye (Auto)

Select all that apply

Injured eye (Auto)

Left

Right

Injured part of face (Auto)

Left

Right

Injured part of neck (Auto)

Front

Back

Left

Right

Injured shoulder (Auto)

Left

Right

Injured part of elbow: (Auto)

Select all that apply

Injured part of elbow: (Auto)

Front

Back

Left

Right

Injured part of wrist: (Auto)

Select all that apply

Injured part of wrist: (Auto)

Front

Back

Left

Right

Injured part of hand: (Auto)

Select all that apply

Injured part of hand: (Auto)

Palm

Back

Left

Right

Injured finger(s) (Auto)

Thumb (Left)

Index (Left)

Middle (Left)

Ring (Left)

Pinky (Left)

Thumb (Right)

Index (Right)

Middle (Right)

Ring (Right)

Pinky (Right)

Injured part of chest/torso: (Auto)

Select all that apply

Injured part of chest/torso: (Auto)

Left

Right

Injured part of back: (Auto)

Select all that apply

Injured part of back: (Auto)

Upper

Lower

Left

Right

Injured part of stomach/abdomen: (Auto)

Select all that apply

Injured part of stomach/abdomen: (Auto)

Left

Right

Injured part of hip: (Auto)

Select all that apply

Injured part of hip: (Auto)

Front

Back

Left

Right

Injured part of knee: (Auto)

Select all that apply

Injured part of knee: (Auto)

Front

Back

Left

Right

Injured part of ankle: (Auto)

Select all that apply

Injured part of ankle: (Auto)

Inner

Outter

Left

Right

Injured part of foot: (Auto)

Select all that apply

Injured part of foot: (Auto)

Top

Bottom

Left

Right

Injured toe(s): (Auto)

Select all that apply

Injured toe(s): (Auto)

Big Toe (Left)

Index (Left)

Middle (Left)

Fourth (Left)

Pinky (Left)

Big Toe (Right)

Index (Right)

Middle (Right)

Fourth (Right)

Pinky (Right)

Injury location - other (Auto)

Please specify other injury location

Nature of injury: (Auto)

Abrasion, scrapes

Amputation

Broken bones

Bruises

Burn (due to chemicals)

Burn (due to heat)

Crushing injury

Cut, laceration, puncture

Damage to body system

Groin injury

Head injury

Sprain, strain

Other

Nature of injury other: (Auto)

Please specify other

Was medical treatment offered at time of Incident? (Auto)

Yes

Who offered the treatment: (Auto)

Regardless if medical treatment was offered, did you receive medical treatment? (Auto)

Yes/Immediately

Yes/at a later date

Date of Treatment: (Auto) (mm/dd/yyyy)

Type of medical treatment received: (Auto)

Med Express/Urgent Care

DU Health Services

First Aid Kit

Emergency Room

Facility Name/Provider: (Auto)

Name/Location of Facility: (Auto)

Explain why medical treatment was refused: (Auto)

Building: (FM)

Room Number/Name: (FM)

Was Facilities Managed Equipment involved? (FM)

(For example, fume hood, boiler, generator, HVAC system, fire pump, etc.)

Was Facilities Managed Equipment involved? (FM)

Yes

Facilities Managed Equipment Description: (FM)

Were chemicals involved? (FM)

Yes

Name of chemical: (FM)

Quantity of chemical: (FM)

Describe step-by-step the events leading up to and during the Incident: (FM)

(Include the names of any machines, tools, parts, objects, materials, chemicals, etc.)

Was a fire extinguisher used? (FM)

Yes

What Personal Protective Equipment (PPE) was being worn at the time of the Incident? (FM)

Safety Glasses/Goggles

Face shield

Gloves

Lab Coat

None

Other

Please specify PPE other: (FM)

Did the incident result in any property damage? (FM)

Yes

Please provide a description of the property damaged from the incident: (FM)

Did the Incident result in any physical injuries? (FM)

Yes

Injury Description: (FM)

Describe as thoroughly as possible the events leading up to and during the injury. Include the names of any machines, tools, parts, objects, materials, chemicals, and all other important details:

Please describe the injury: (FM)

Injured arm: (FM

Select all that apply

Injured arm: (FM

Left

Right

Injured leg: (FM)

Select all that apply

Injured leg: (FM)

Yes

Injured part of head: (FM)

Select all that apply

Injured part of head: (FM)

Front

Back

Left

Right

Injured eye: (FM)

Select all that apply

Injured eye: (FM)

Left

Right

Injured part of face: (FM)

Left

Right

Injured part of neck: (FM)

Front

Back

Left

Right

Injured shoulder: (FM)

Left

Right

Injured part of elbow: (FM)

Select all that apply

Injured part of elbow: (FM)

Front

Back

Left

Right

Injured part of wrist: (FM)

Select all that apply

Injured part of wrist: (FM)

Front

Back

Left

Right

Injured part of hand: (FM)

Palm

Back

Left

Right

Injured finger(s): (FM)

Thumb (Left)

Index (Left)

Middle (Left)

Ring (Left)

Pinky (Left)

Thumb (Right)

Index (Right)

Middle (Right)

Ring (Right)

Pinky (Right)

Injured part of chest/torso: (FM)

Select all that apply

Injured part of chest/torso: (FM)

Left

Right

Injured part of back: (FM)

Upper

Lower

Left

Right

Injured part of stomach/abdomen: (FM)

Select all that apply

Injured part of stomach/abdomen: (FM)

Left

Right

Injured part of hip: (FM)

Front

Back

Left

Right

Injured part of knee: (FM)

Front

Back

Left

Right

Injured part of ankle: (FM)

Select all that apply

Injured part of ankle: (FM)

Inner

Outter

Left

Right

Injured part of foot: (FM)

Top

Bottom

Left

Right

Injured toe(s): (FM)

Big Toe (Left)

Index (Left)

Middle (Left)

Fourth (Left)

Pinky (Left)

Big Toe (Right)

Index (Right)

Middle (Right)

Fourth (Right)

Pinky (Right)

Injury location - other: (FM)

Please specify other injury location

Nature of injury:

Abrasion, scrapes

Amputation

Broken bones

Bruises

Burn (due to chemicals)

Burn (due to heat)

Crushing injury

Cut, laceration, puncture

Damage to body system

Groin injury

Head injury

Illness

Other

Sprain, strain

Nature of injury other: (FM)

Please specify other

Was medical treatment offered at time of Incident? (FM)

Yes

Who offered the treatment: (FM)

Regardless if medical treatment was offered, did you receive medical treatment? (FM)

Yes/Immediately

Yes/at a later date

Date of Treatment: (FM)

Type of medical treatment received: (FM)

Med Express/Urgent Care

DU Health Services

First Aid Kit

Emergency Room

Name/Location of Facility: (FM)

Facility Name/Provider: (FM)

Explain why medical treatment was refused: (FM)

Building: (Lab)

This section should be filled out for Incidents that occur in laboratories or other hazardous environments pertaining to University facilities.

Room Number/Name: (Lab)

Was Laboratory Equipment involved?

Yes

Laboratory Equipment Description:

Was Facilities Managed Equipment involved? (Lab)

(For example, fume hood, boiler, generator, HVAC system, fire pump, etc.)

Was Facilities Managed Equipment involved? (Lab)

Yes

Facilities Managed Equipment Description:

Were chemicals involved? (Lab)

Yes

Name of chemical: (Lab)

Quantity of chemical: (Lab)

Were biological materials involved? (Lab)

Yes

Name of biological material: (Lab)

Quantity of Biological Material: (Lab)

Were radioactive materials involved? (Lab)

Yes

Name of radioactive material: (Lab)

Quantity of radioactive material: (Lab)

Describe step-by-step the events leading up to and during the Incident: (Lab)

(Include the names of any machines, tools, parts, objects, materials, chemicals, etc.)

Was a fire extinguisher used? (Lab)

Yes

What Personal Protective Equipment (PPE) was being worn at the time of the Incident? (Lab)

(Check all that apply)

What Personal Protective Equipment (PPE) was being worn at the time of the Incident? (Lab)

Safety Glasses/Goggles

Face shield

Gloves

Lab Coat

None

Other

Please specify PPE other: (Lab)

Did the incident result in any property damage? (Lab)

Yes

Injury Description: (Lab)

Describe as thoroughly as possible the events leading up to and during the injury. Include the names of any machines, tools, parts, objects, materials, chemicals, and all other important details:

Please describe the injury: (Lab)

Injured arm (Lab)

Select all that apply

Injured arm (Lab)

Left

Right

Injured leg (Lab)

Select all that apply

Injured leg (Lab)

Yes

Injured part of head (Lab)

Select all that apply

Injured part of head (Lab)

Front

Back

Left

Right

Injured eye (Lab)

Select all that apply

Injured eye (Lab)

Left

Right

Injured part of face (Lab)

Select all that apply

Injured part of face (Lab)

Left

Right

Injured part of neck (Lab) Injured part of neck (Lab)

Front

Back

Left

Right

Injured shoulder (Lab)

Left

Right

Injured part of elbow: (Lab)

Select all that apply

Injured part of elbow: (Lab)

Front

Back

Left

Right

Injured part of wrist: (Lab)

Select all that apply

Injured part of wrist: (Lab)

Front

Back

Left

Right

Injured part of hand: (Lab)

Select all that apply

Injured part of hand: (Lab)

Palm

Back

Left

Right

Injured finger(s): (Lab)

Select all that apply

Injured finger(s): (Lab)

Thumb (Left)

Index (Left)

Middle (Left)

Ring (Left)

Pinky (Left)

Thumb (Right)

Index (Right)

Middle (Right)

Ring (Right)

Pinky (Right)

Injured part of chest/torso: (Lab)

Select all that apply

Injured part of chest/torso: (Lab)

Left

Right

Injured part of back: (Lab)

Select all that apply

Injured part of back: (Lab)

Upper

Lower

Left

Right

Injured part of stomach/abdomen: (Lab)

Select all that apply

Injured part of stomach/abdomen: (Lab)

Left

Right

Injured part of hip: (Lab)

Select all that apply

Injured part of hip: (Lab)

Front

Back

Left

Right

Injured part of knee: (Lab)

Select all that apply

Injured part of knee: (Lab)

Front

Back

Left

Right

Injured part of ankle: (Lab)

Select all that apply

Injured part of ankle: (Lab)

Inner

Outter

Left

Right

Injured part of foot: (Lab)

Select all that apply

Injured part of foot: (Lab)

Top

Bottom

Left

Right

Injured Toe(s): (Lab)

Select all that apply

Injured Toe(s): (Lab)

Big Toe (Left)

Index (Left)

Middle (Left)

Fourth (Left)

Pinky (Left)

Big Toe (Right)

Index (Right)

Middle (Right)

Fourth (Right)

Pinky (Right)

Nature of injury: (Lab)

Select from the menu all that apply to your injury or injuries

Nature of injury: (Lab)

Abrasion, scrapes

Amputation

Broken bones

Bruises

Burn (due to chemicals)

Burn (due to heat)

Crushing injury

Cut, laceration, puncture

Damage to body system

Groin injury

Head injury

Illness

Other

Sprain, strain

Nature of injury other: (Lab)

Please specify other

Injury location - other: (Lab)

Please specify other injury location

Was medical treatment offered at time of Incident? (Lab)

Yes

Who offered the treatment: (Lab)

Regardless if medical treatment was offered, did you receive medical treatment? (Lab)

Yes/Immediately

Yes/at a later date

Type of medical treatment received: (Lab)

Med Express/Urgent Care

DU Health Services

First Aid Kit

Emergency Room

Name/Location of Facility: (Lab)

Facility Name/Provider: (Lab)

Explain why medical treatment was refused: (Lab)

Please provide a description of the property damaged from the incident:

Did the Incident result in any physical injuries? (Lab)

Yes

Please provide a description of the property damaged from the incident: (Lab)

If the Incident does not seem to fall under one of the other categories indicated above:

Please describe the nature and events leading up to and during the Incident as thoroughly as possible.

Injury Description:

Describe as thoroughly as possible the events leading up to and during the injury. Include the names of any machines, tools, parts, objects, materials, chemicals, and all other important details

Please describe the injury:

Injured arm:

Select all that apply

Injured arm:

Left

Right

Injured leg:

Select all that apply

Injured leg:

Left

Right

Injured part of head:

Select all that apply

Injured part of head:

Front

Back

Left

Right

Injured eye:

Select all that apply

Injured eye:

Left

Right

Injured part of face:

Select all that apply

Injured part of face:

Left

Right

Injured part of neck:

Select all that apply

Injured part of neck:

Front

Back

Left

Right

Injured shoulder:

Select all that apply

Injured shoulder:

Left

Right

Injured part of elbow:

Select all that apply

Injured part of elbow:

Front

Back

Left

Right

Injured part of wrist:

Select all that apply

Injured part of wrist:

Front

Back

Left

Right

Injured part of hand:

Select all that apply

Injured part of hand:

Palm

Back

Left

Right

Injured finger(s):

Select all that apply

Injured finger(s):

Thumb (left)

Index (left)

Middle (left)

Ring (left)

Pinky (left)

Thumb (right)

Index (right)

Middle (right)

Ring (right)

Pink (right)

Injured part of chest/torso:

Select all that apply

Injured part of chest/torso:

Left

Right

Injured part of back:

Select all that apply

Injured part of back:

Upper

Lower

Right

Left

Injured part of stomach/abdomen:

Select all that apply

Injured part of stomach/abdomen:

Left

Right

Injured part of hip:

Select all that apply

Injured part of hip:

Front

Back

Left

Right

Injured part of knee:

Select all that apply

Injured part of knee:

Front

Back

Left

Right

Injured part of ankle:

Select all that apply

Injured part of ankle:

Inner

Outter

Left

Right

Injured part of foot:

Select all that apply

Injured part of foot:

Top

Bottom

Left

Right

Injured toe(s):

Select all that apply

Injured toe(s):

Big Toe (left)

Index (left)

Middle (left)

Fourth (left)

Pinky (left)

Big Toe (right)

Index (right)

Middle (right)

Fourth (right)

Pinky (right)

Injury location - other

Please specify other injury location

Nature of injury:

Select from the menu all that apply to your injury or injuries.

Nature of injury:

Abrasion, scrapes

Amputation

Broken bones

Bruises

Burn (due to chemicals)

Burn (due to heat)

Crushing injury

Cut, laceration, puncture

Damage to body system

Groin injury

Head injury

Illness

Other

Sprain, strain

Damage to body system explanation:

Nature of injury other:

Please specify other

Was medical treatment offered at time of Incident?

Yes

Who offered the treatment:

Regardless if medical treatment was offered, did you receive medical treatment?

Yes/Immediately

Yes/at a later date

Date of Treatment: (mm/dd/yyyy)

Type of medical treatment received:

Med Express/Urgent Care

DU Health Services

First Aid Kit

Emergency Room

Name/Location of Facility:

Facility Name/Provider:

Explain why medical treatment was refused:

Were you injured during the course of your employment duties? (employee)

Yes

Employee work day/shift start time: (mm/dd/yyyy hh:mm AM/PM)

Employee work day/shift end time: (mm/dd/yyyy hh:mm AM/PM)

Workers Compensation Agreement Disclosure

* Please complete if you are an employee who sustained an injury

Please read, complete, sign and submit the Pennsylvania Workers’ Compensation forms. Treatment must be provided by the physician’s designated on the list below:

https://intranet.duq.edu/work-at-duquesne/for-a...

I confirm that I have received the information on the Pennsylvania Workers’ Compensation forms and will attach a completed copy to this Incident Report Form or email them separately to benefits@duq.edu.

Workers Compensation Agreement Disclosure

I agree to the above Workers Compensation Agreement

Are you a student worker?

Yes

Were you injured during the course of your employment duties?

Yes

Normal work hours start time: (mm/dd/yyyy hh:mm AM/PM)

Normal work hours end time: (mm/dd/yyyy hh:mm AM/PM)

Is your supervisor aware of this incident? (Student)

Your supervisor will receive a copy of this Incident report and will be required to review, acknowledge and add comments as needed.

Is your supervisor aware of this incident? (Student)

Yes

Supervisor’s Name:

Supervisor’s Telephone Number:

Supervisor's Email:

Attachment

Please include any photos, receipts, or any other documentation.

Browse...

If you have issues uploading attachments with the form, please submit your ticket and send attachments to Courtney Ozanich at ozanichc1@duq.edu.

Other Fields

Your name

Your first name

Your last name

Your email address

Your phone number

Verification Code