PERSONAL INFORMATION

1. Name: (Last, First, M.I.): 2. Local Address: On Campus? YES NO 3. Home Phone: 4. Date of Birth: 5. Sex: Male Female 6. WKU Student? Yes No 7. Visitor? Yes No

ACCIDENT INFORMATION

1. Date of Accident: 2. Time: 3. Activity at Accident: 4. Estimate of Severity: Non-disabling, less than one work day Light duty restriction Disabling, more than one work day  Fatal  5. Division 6. Supervisor 7. Action to prevent accidents 8. Property Damage 9. Type of Facility Administrative Office  Auditorium or Library  Athletic Competition  Bath, Shower, or locker  Building Exterior  Classroom or Hall  Eating Place  Sidewalk  Farm or field  Food preparation  Gymnasium  Home Economics  Housing  Hall  Stairway  Intramurals  Laboratory  Medical Facility  Physical Education  Playing field  Private Activity  Public Activity  Recreation or Entertainment  Retail shop  Maintainence Area  Sports area  Storeroom  Street  Swimming Pool  Transportation  Undeveloped Area  Water Area  Other  10. Witnesses: 11. Location of Accident:  12. Jurisdiction On WKU Property  Off campus and not University related  13. Agent Causing Accident: Animal Bites  Athletics  Broken Glass  Broken pavement  Chemicals  Moving Object  Foreign object in eye  Gases  Hand Tools  Hot liquid/object  Icy conditions  Lifting or carrying object  Miscellaneous Kitchen Equipment  Off balance  Office Equipment  Power tools and machinery  Radiation  Sharp edged object  Sharp pointed object  Slipping  Striking with body  Tripping  Welding Light  Miscellaneous  Unknown  More: 14. Nature of Injury: Amputation  Bruise  Burn, scald  Concussion  Cut or wound  Dermatitis infection  Exposure, Frostbite  Fracture  Foreign Body  Heat Exhaustion, Sunstroke  Inhalation - Dust  Inhalation - fumes  Internal injury  Poisoning  Puncture  Electric Shock  Fainting Shock  Sprains or dislocations  Suffocation, drowning, strangling  Rupture, Hernia  More: 15. Body Part Injured: Generalized  Skull or scalp  Eye  Nose  Mouth  Jaw  Neck  Spine  Chest  Abdomen  Back  Pelvis  Trunk  Shoulder  Upper arm  Elbow  Wrist  Hand  Finger  Thigh  Ankle  Knee  Foot  Hip  Lower Leg  Toe  More: 16. Details of Accident: 17. Emergency Care & Patient Status: First aid only, no hospital or doctor  Treatment at University Health service  Physician visit  Hospital, Emergency room    Other:

AUTHORIZED SIGNATURES