Incident Report Form

If you are an employee of NSHE, UNLV, CSN, or NSC and were injured while working, complete a C-1 form and report your work injury to your supervisor. Do not complete this form.

Name:

Email:

Telephone Number:

Institution Affiliation:

Institution:

Building Address / Location Information:

Date of Incident:

Time of Incident:

Type of Incident:

Description of Incident: Include Names, Contact Information, Dates, and Times. Describe in Detail Objects, People, Direction of Travel, Property Damage, Vehicle Make, Model, Color, License Plate (Including State), and Weather Conditions, etc.

Was there police, fire, or other first responders at the scene of the incident?

First Responders on Scene: Hold down the Ctrl (windows) / Command (Mac) button to select multiple options.

Was a police report generated?

Type police report number below. If multiple departments issued reports, list each department that issued a police report and the corresponding report number:

Upload Relevant Files (Max 10 files): Include any supporting documents such as photos, police, and fire reports.

I verify that the information submitted on this form is true and correct to the best of my knowledge. By typing my name below, an electronic signature will be created. My electronic signature will be treated in all respects as having the same force and effect as an original (wet) signature. By selecting the submit button, I agree with the aforementioned statement.

Full Name: