Student Accident Incident

The injured student and/or Department Representative should fill out this form.

NOTE: Students employed by W&M who are injured while at work should fill out the First Report of Accident/Injury Form located on the University Human Resource website.

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Basic Information

Student Name* Required

Curriculum

Home Address

Phone

Date of Injury* Required

Time of Injury* Required

Student Identification Number* Required

Accident Information

Please describe in detail how the accident happened. What was the student doing? List any specific acts by individuals or conditions that led to the accident (include any tools, machinery or instruments involved).* Required

Additional Information

Was first aid administered?* Required

Was medical treatment sought at the Student Health Center* Required

Name of treating physician

Did accident occur during class time?* Required

If yes, provide class name and instructor

Remarks

What recommendations do you have for preventing other accidents of this type?* Required

Add Supporting Documents

Add files to upload as supporting documentation along with your incident report.