UVM Incident Report Form

Date
Time of Incident

Name of Person Reporting the Incident

Phone Number
Bodily Injury
Location of Accident
Name of Person(s) Injured
 
Describe What Happened
Emergency Medical Treatment Given
Medical Treatment Administered by:

 

Describe What Was Done
Was the person taken to the hospital?
Name of Hospital
Were the Police Called to the Scene?
 
Name of Police Department Name of Police Officer:
Property Damage: (including damage to another's vehicle)  
Type of Property: Location of Property:
   
Please submit this form to the UVM Department of Risk Management. All information will be kept confidential.