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Student Injury/Illness Report

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Welcome to the Student Injury/Illness Reporter!

This information will be used by EHS (Environmental Health and Safety) to follow up on student injury/illnesses that may have resulted from an uncontrolled hazard. This reporting tool is intended only for students that do not have "employee" status and which have not filed for workers compensation benefits, as described in the EHS SOP, On the Job and Student Injuries.

Injured/Illness information:

Student UNL ID
Student Name
Email Address
Contact Phone Number
Date Incident Happened
Time of Incident
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Submitter information if different then above:

Submitter Name
Submitter Email Address
Submitter Phone Number

Location of Incident

Name of Responsible Faulty/Staff for Area

Describe the Nature of your Injury/Illness

Brief Description of what Caused the Injury/Illness

What might have Prevented this Injury/Illness

Additional Information/Comments