Employee Status

Employee

Student Employee

Student

Visitor

Field is required

Full name

Field is required

CWU ID

Field is required

Email

Field is required, and needs to be a valid email address.

Phone

Field is required

Date of accident

Field is required

mm/dd/yyyy

Time of Accident

Field is required

hh:mm

Where did the accident occur?

Field is required

Type of Injury?

Field is required

Body part injured?

Field is required

Date Reported

Field is required

mm/dd/yyyy

Time Reported

Field is required

hh:mm

Reported to

Field is required

Description of Accident

Field is required

Factors contributing to accident

Field is required

Chemicals, or equipment involved

Field is required

Suggestions for corrections

Field is required

Witness Information

Field is required

Name, address, and phone number

Medical Treatment Received

Field is required

I agree, to the best of my ability and knowledge, that all information I have given above is true and correct

Field is required

reCAPTCHA is a required field. Please complete this field.

Submit