CUSTOMER/VISITOR REPORT OF INJURY
THIS REPORT SHOULD BE COMPLETED WHEN ANY INJURY OCCURS ON STATE OWNED OR CONTROLLED PROPERTY.  THIS REPORT SHOULD BE COMPLETED AND SUBMITTED TO THE RISK MANAGEMENT DIVISION WITHIN 24 HOURS.
Please make no comment regarding liability, fault or blame.

Customer/Visitor information:
1.	  Name: _________________________________________________________________________________   
(Please include parent or guardian’s name if the injured is a minor)

2.  Mailing Address: 													   
		                    (Street)                                                                (City)                                                                 (State)                              (Zip)

3.  Daytime Telephone Number:         		          4. Evening Telephone Number:  	 		

5.  Controlling Dept/Agency where injury occurred: 								
 
6.  Date of Injury:  				  7.  Time of Injury:  				   

8.	Where Injury Occurred: 			 									
   				(address, city & state)
.
9.	Describe fully what injury occurred (mention body part(s) affected) and explain how and exactly where the injury occurred:        	     																																																																																						

10.  Witnesses to injury:    Name: 					   Telephone Number: 			    

11.  Injury resulted in what treatment at the site:     First Aid    		   Ambulance/paramedics 	 	                     Other, specifically    													 																																												

12.  What factors, events and/or conditions contributed to the incident? 						                                            
       																		
13.  Did the customer/visitor express any concern about the incident?    Yes 	       No 	 
       If Yes, what was mentioned:											

14.  Name and title of person completing this report: 								   
Date:  					      Time: 					

Signature: 							  Telephone Number: