Report • CampusOptics

Every report is a learning opportunity. Thank you for your commitment to timely and accurate incident reporting.

All work-related incidents must be documented immediately. Please ensure all required fields are completed.

The supervisor must:

Report the injury/illness (with the employee present, if possible) to Amerisys at 1-800-455-2079
Investigate the incident and complete this report within 24 hours when an individual who is an employee or volunteer of USF suffers injury, illness, or exposure while acting within that person's employment or agency with USF, at a USF location, or at a USF sponsored event.

The report must be completed by the USF supervisor with input from the employee (if available)

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Name* Required

Floor or Area* Required

Additional Location Details

Exact Location

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No Location Set

Latitude

Longitude

Intro

Incident categorization* Required

Classification of Injured, Ill or Exposed Person

Contractor type

Student Injury Illness Report

At the time of the injury, illness, or exposure the affected student was:* Required

What was the affected student doing?

Information about the injured/ill person

Name of Injured Person* Required

Gender* Required

Campus (Internal)

Tampa

St. Petersburg

Sarasota/Mantatee

TGH/Advent/VA

Downtown

Research Park

Off campus

If 'off campus' please explain

Job Title* Required

Department* Required

Employee ID Number

Work Phone* Required

Home Phone

Email (optional)* Required

Has the injury/illness been reported to AmeriSys?* Required

Workers' Compensation Claim Number (optional)

Information about this injury/illness

Date of Injury/Illness* Required

Time injury occurred or illness began* Required

Date Injury/Illness Reported to Supervisor (mm/dd/yyyy)* Required

Time Injury/Illness Reported to Supervisor (hh:mm am or pm)* Required

Witnesses

Were biological hazards, radiological hazards, or research animals involved in the incident?

Biological Hazard

Radiological Hazard

Research Animal

Describe, in detail, what happened to cause the injury/illness* Required

Describe the injury and part(s) of the body injured* Required

Medical response or treatment* Required

Basic First Aid

Hospital/Urgent Care

Medical Response Unit/Ambulance

Student Health center/MRU

Refused

N/A

Was a police report completed?* Required

Provide police agency and report number* Required

Supervisor's Injury Illness Report

Did the employee lose consciousness?* Required

Did the employee suffer fatal injuries?* Required

Contributing Factors

Was the injury/illness caused by an unsafe behavior?* Required

Was the injury/illness caused by a missing or inadequate policy or procedure?* Required

What other factors contributed to the injury/illness?* Required

Allergic Reaction

Chemical Exposure

Defective Tool, Equipment, or Machinery

Ergonomic Environment Needs Improvement

Excessive Noise

Failure to Follow Proper Procedures

Failure to Use Personal Protective Equipment (PPE)

Fall

Hot Surface

Lack of (or improper) Training

Lifting/Material Handling

Repetitive Activities

Situational Awareness

Slippery/Uneven Surface

Temperature

Trip Hazard

Use of Wrong Tool, Equipment or Machinery

Weather Conditions

Other

None of these

Provide an explanation of the factors listed above that contributed to the injury/illness* Required

Has the affected person received prior training to perform the task(s) involved properly and safely?* Required

Date and title of the training

List corrective actions completed or to be completed by supervisor to prevent this injury/illness from recurring

Supervisor's Name* Required

Supervisor's Phone Number* Required

Supervisors Email Address* Required

Non-employee question block

Injured persons Address, City, State, Zip, Country (if other than USA)* Required

Date and Time of Injury/Illness* Required

Program or Event

Can you provide contact information for the person in charge?* Required

Name of Person In Charge* Required

Email of Person In Charge* Required

Phone of Person In Charge

Fire

Classification of person reporting fire* Required

Contractor type (fire)

Date fire occurred* Required

Time fire occurred* Required

What campus did fire occur* Required

Downtown

Tampa

TGH/Advent/VA

Sarasota/Mantatee

St. Petersburg

Other

Location of fire* Required

Fire Classification* Required

Auto Fire

Building Fire

Electrical Fire

Equipment Fire

Wildfire/Exterior

Other

If 'other' fire classification please specify.* Required

What was the cause of the fire

Were the police notified?* Required

Was the fire department notified?* Required

Was there property damage?

Environmental Spill or Release

Classification of person reporting spill/release* Required

Contractor type (Spill/Release)

Date spill/release occurred* Required

Time spill/release occurred* Required

Campus where environmental spill/release occured* Required

Downtown

Tampa

TGH/Advent/VA

Sarasota/Mantatee

St. Petersburg

Other

If 'other" location for environmental spill/release please explain.

What happened to cause spill/release* Required

What material was involved* Required

Where did spill/release take place* Required

How much material was released* Required

What system (drinking water, storm water, etc.), building, residential area or wildlife area was affected.* Required

Names of any witnesses of spill/release and their contact information

Describe any immediate actions that were taken to address spill/release

Property Damage

Classification of person reporting Property Damage* Required

Contactor type (Property damage)

Date property damage occurred* Required

Time property damage occurred* Required

What campus did property damage occur* Required

Downtown

Tampa

TGH/Advent/VA

Sarasota/Mantatee

St. Petersburg

Other

If 'other' location for property damage please explain

Type of property damage* Required

Appliance malfunction

Construction related

Fire

Flood

Hail

Hurricane

Lightning

Falling object

Freezing

Riot/civil commotion

Roof leak

Sinkhole

Smoke

Structural failure

Theft

Vandalism

Windstorm

Other

If 'other' type of property damage please explain.

Location of incident and/or property damage* Required

What happened to cause property damage* Required

Is the responsible party for property damage known

Were police contacted for property damage?* Required

Police report number for property damage

Vehicle accident

Classification of person reporting Vehicle/Cart accident* Required

Contractor type (vehicle/cart accident)

What is the date of the accident* Required

What is the time of the accident* Required

What campus did vehicle accident occur* Required

Downtown

Tampa

TGH/Advent/VA

Sarasota/Mantatee

St. Petersburg

Other

If 'other' location for vehicle accident please explain.

What type of vehicle was involved in the accident* Required

Car/Truck

Golf Cart

UTV

Other

If "other" was selected for vehicle type please specify, if applicable* Required

Were the police contacted for the vehicle accident?* Required

Police report number for accident* Required

Medical response or treatment for accident* Required

Who was injured in accident* Required

Driver

Passenger

Pedestrian

Is there any damage to any vehicles or property* Required

Vehicle(s)

Property

N/A

Were there any tickets or citations issued* Required

Other Reportable Event

Classification of person reporting "other" event* Required

Contractor type (other)

Date of "other" incident* Required

Time "other" event was observed* Required

What campus did "other" event occur* Required

Downtown

Tampa

TGH/Advent/VA

Sarasota/Mantatee

St. Petersburg

Other

Where was this "other" event observed* Required

What happened in this "other" event* Required

Who was involved in this "other" event* Required

Did the "other" event lead to any direct or potential harm of any person(s)* Required

Yes

N/A

Was the "other" event resolved* Required

Yes

N/A

Was anyone else notified for this "other" event* Required

Facilities/Maintenance/Grounds

Police

Supervisor/Manager

USF Employee

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