Student Accident or Injury Report Form

The Accident or Injury Report Form should be used to report any accident that resulted in bodily injury or illness that occurred on Goodwin property or on a Goodwin sponsored or approved activity off campus. In the case of immediate threat or an emergency call 9‑1‑1.

Please contact the Director of Campus Safety and Security at 860‑913‑2023 with questions about accident or injury reporting.

Reporting Party Information

Your Full Name

Phone

Department

Supervisor

Individual(s) Involved In The Incident

Individual 1

Name:

Student ID:

Phone

Individual 2

Name:

Student ID:

Phone:

Email:

Individuals (if any) Affected By The Incident/Witnesses

Affected Individual 1

Name:

Student ID:

Phone:

Email:

Affected Individual 2

Name:

Student ID:

Phone:

Email:

Affected Individual 3

Name:

Student ID:

Phone:

Email:

Description of Incident

Date:

Time:

Location:

Factual description of alleged incident (Please describe the incident using facts, observation, and witnesses. AVOID personal judgments and/or feelings and hearsay.

If you have additional supporting evidence/documents please email them to Rich Vibberts at RVibberts@goodwin.edu.

Description

If you are human leave this field blank