Follow the steps to complete the form easily.

1. Click ‘Get Form’ button to access the form and open it in the editing tool.
2. Select your status as either a student or a visitor by marking the appropriate checkbox.
3. Enter the date of the injury or illness in the format M/D/YY.
4. Specify the time of the injury or illness, selecting AM or PM accordingly.
5. Provide your name in the format of Last, First, MI, along with your home telephone number.
6. Fill out your address details, including street, city, state, and zip code.
7. Indicate whether medical attention will be required for this injury or illness by selecting 'Yes' or 'No.'
8. Document the address or location where the injury or exposure occurred, including building number or street, city, state, and zip.
9. Specify the specific location of the injury or exposure (e.g., stairs, dock, lab).
10. Describe the nature of the injury or illness (e.g., cut, sprain, illness).
11. Identify the body part involved (e.g., left arm, right eye).
12. Explain the cause of the injury or illness (e.g., slip or fall, chemical).
13. Provide a detailed account of how and why the injury or illness occurred.
14. Enter the doctor’s name, address, and telephone number if applicable.
15. List any witnesses and include their statements, using additional sheets if necessary.
16. If the form is filled out by someone other than the injured person, provide their contact information (name and telephone number).
17. Once completed, save your changes, and choose to download, print, or share the form.

Take the next step towards documenting your incident by completing the form online today.