Office of Risk Management

For some reason the following message is just not getting across to people. If you were injured on the job - do not use this form!

DO NOT use this form to report injuries or illness. For occupational injuries or illness, click on: IU Occupational Injury Illness Report or IUPUI Occupational Injury Illness Report or call 812-855-4847. This form may be used to report any other type of incident.

In the event of an incident involving serious injury, please return to our first page and page someone for an immediate response.

Your name		Your telephone number
Your cell phone no.		Pager
Your email address		Your address (Campus address, if applicable)

Date and time of incident	Date Time	If this occurred on campus...
Location Be as specific as possible		Description of accident Be as complete as possible
If a policeman was there: Department and case # (if known)		Injuries?
If an IU vehicle(s) was involved please list their numbers		Witness names and contact information (telephone, address), if any