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FORMCHECKBOX Hallway FORMCHECKBOX Sidewalk FORMCHECKBOX Icy FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Lobby/Entrance FORMCHECKBOX Stairway FORMCHECKBOX Snowy FORMTEXT      UPD Report # FORMTEXT       FORMCHECKBOX Office/Classroom FORMCHECKBOX Street FORMCHECKBOX Wet FORMCHECKBOX Other:  FORMTEXT       FORMCHECKBOX Not ReportedINCIDENT DESCRIPTIONDescribe What Happened (Use additional sheet if necessary): FORMTEXT      INJURED PERSONNameAgePhone No. FORMTEXT       FORMTEXT       FORMTEXT      AddressEmployee UIN#: FORMTEXT       FORMTEXT      DESCRIPTION OF INJURY & MEDICAL TREATMENTInjury - Describe the type, severity, and body part involved FORMTEXT      Was Medical Treatment Given?Yes FORMCHECKBOX No FORMCHECKBOX Will seek treatment later FORMCHECKBOX Name of Medical Facility/Doctor FORMCHECKBOX Transported by Ambulance FORMTEXT       FORMTEXT       FORMCHECKBOX Transported by Other: FORMTEXT      PROPERTY DAMAGEOwner s NameAddressPhone # FORMTEXT       FORMTEXT       FORMTEXT      Describe the property and the damage: FORMTEXT      WITNESSES Give the Full Name and Number of Each Witness Including Permanent AddressNameAddressPhone # FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Name/Title of the Employeecompleting this Report FORMTEXT      Phone #: FORMTEXT      Department FORMTEXT      Date FORMTEXT       Section 2: To be completed by Supervisor/SuperintendentNote: After speaking to the employee and investigating the incident, the Supervisor / Superintendent is to complete the following: WAS THERE AN UNSAFE ACT OR PRACTICE?Describe What Happened (Use additional sheet if necessary): FORMTEXT      WAS THERE AN UNSAFE WORKING CONDITION?Describe The Conditions (Use additional sheet if necessary): FORMTEXT      What actions have you taken to prevent a similar incident?Describe The Precautionary Measures (Use additional sheet if necessary): FORMTEXT       Name/Title of the Supervisor / Superintendentcompleting this Report FORMTEXT      Phone #: FORMTEXT      Department FORMTEXT      Date FORMTEXT       Section 3: To be completed by Director/ChairNote: This section must be completed by the Director / Chair of the Department and HYPERLINK "mailto:kujrb001@tamuk.edu;%20Theresa.Perez@tamuk.edu?subject=TAMUK%20Incident%20Report&body=Save%20and%20Attach%20Incident%20Report%20to%20this%20E-mail"forwarded to the EHS and HR offices Click Here for E-Mail :DOES YOUR DEPARTMENT HAVE AN ESTABLISHED RULE / POLICY RELATED TO THIS INCIDENT?Yes  FORMCHECKBOX No  FORMCHECKBOX N/A  FORMCHECKBOX Was the rule/policy violated in this incident? Yes  FORMCHECKBOX  No  FORMCHECKBOX Within your department what measures have you taken to prevent or minimize the recurrence of a similar incident?  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