Incident Report Form

INCIDENT REPORT FORM

The prevention of accidents and the promotion of safety are the responsibility of everyone in the GSU community. Everyone is encouraged to be alert to and report any unsafe practices and conditions that may present an imminent danger to individuals or property. Employees should report these types of conditions immediately to their immediate supervisor, designee, or to IRM.

Incident Report Form Print Version

Incident Report Form

This Incident Report Form is for reporting general incidents only. For example, slip & fall, tripping, or reporting a hazard. All incidents must be reported within 24 hours to the Department of Safety & Risk Management.
General Information
Department*
Name of Person Reporting Incident*
Title
Email*
Phone*
Fax
Incident Information
Date of Incident*
Date Format: MM slash DD slash YYYY
Time of Incident
Address of Incident
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Campus
Building
Affected Rooms
Affected Floors
Incident Description
Has area been secured?
- Yes
- No
If no, what is being done to secure area?
Has the incident been reported to the police?
- Yes
- No
If yes, please provide Police Report #
Witness Information
Witness 1
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Witness 2
First Last
Email
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone

Our Staff

Frederick Bibbs
Director, Insurance & Risk Management
Tel: 404-413-9548
[email protected]

Lajanda Casey
Insurance & Risk Coordinator
Tel: 404-413-9546
[email protected]

Vacant
Administrative Specialist, Administrative
Tel: 404-413-9545

Crystal White
Occupational Health and Safety Officer
Tel: 404-413-9547
[email protected]

Office Hours

Monday-Friday,
8:30 a.m.-5:15 p.m.

Fax: 404-413-9550
Email: [email protected]

Office Location

Citizens Trust Building
75 Piedmont Avenue
Suite 506
Atlanta GA 30302

Emergency Numbers

Emergencies: 911
Campus Police: 404-413-3333

Mailing Address

Georgia State University
Department of Insurance & Risk Management
P.O. Box 3961
Atlanta GA 30302-3961

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