Incident Report • CampusOptics

The Risk & Safety Incident Report form is utilized to capture near miss and incident reports across campus. This form will be used to capture information for response calls to help UTD Risk & Safety mitigate any safety related issues and/or concerns on campus. Please complete this form to initiate a follow up response from the team.

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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Initial Report

Affiliation of Affected Party

Type of Report

Date of Incident

Name(s) of individual(s) involved in the incident

Name(s) of individuals who witnessed the incident

Supervisor's Name

Incident Details (Tell us who, what, when, where and why)

Were hazardous materials released?

If yes, what was the hazardous material(s)?

Did an injury or illness occur?

Medical treatment initially utilized?

Was emergency personnel notified? (Police, Public Safety Officer, and/or Emergency Management)

Was there property damage or loss?

If yes, where was the property damage?

Add Supporting Documents

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