Environmental Health, Safety & Risk Management
General Incident Report
Date: ___________________
Please complete for any incident, accident, near miss or environmental release.
Note: If injured party is a UTRGV employee, please submit the First Report of Injury or Illness Form. Contact Celia Saenz
at (956) 665-3690 or download form at www.utrgv.edu/ehsrm/programs/risk-mana/workers-comp/
Reporting Party Information
Last name
First Name
Email
Address
City
State
Zip
Telephone
Injured Party Information
Is the injured party the same as reporting party? [ ] Yes [ ] No
If “No”, please provide injured party information.
Last name
First Name
Email
Address
City
State
Zip
Telephone
Status
[ ] Student [ ] Visitor [ ] Volunteer [ ] Other __________________________
Environmental Health, Safety & Risk Management
Incident Information
Date of injury
Time of injury
Location of injury
Was this injury part of a school sanctioned activity or event?
[ ] Yes [ ] No
If yes, specify event or sanction activity.
Did injury require a visit to a physician?
[ ] Yes [ ] No
Did injury require hospitalization?
[ ] Yes [ ] No
Injury / Accident / Near Miss / Environmental Release
(Explain in detail the nature of the accident and the cause of the injury)
[ Submit ]
To submit this form, you may either:
1. Click on the “Submit” button to send this form automatically as an email attachment.
2. Print, scan, and email this form to EHSRM@UTRGV.EDU or
3. Send via inter-departmental mail to Environmental Health, Safety and Risk Management Offices in
Edinburg - EEHSB 1.110
or
Brownsville - BASFC 1.225A.
Submit
