University of Kentucky
ACCIDENT - INJURY REPORT
Name (Last, First): SS# (last 4 digits):
Campus Address:
(Visitors - Home Address)

Age: Sex: F M
Form Prepared by (Name & email address):

Employee's Department Number: Job Title:
Supervisor: Date Employed (month, year):
Phone: Date of Accident:
Location of Accident: Time: am pm
Conditions:(dark, icy) Activity at Time:
List Equipment Used:

Classification:

FACULTY STAFF VISITOR OTHER STUDENT
Freshman Sophomore Junior Senior Graduate

Type of Facility:
If you chose other please describe:

Nature of Injury:
If you chose other please describe:

Exact Part of Body Injured:
If you chose other please describe:

Agent Causing Injury/Illness:
If you chose other please describe:

Please enter the details of the accident below:

Please enter what action was taken to prevent similar accidents below:

Click here if you are ready to submit the form.

This form will be sent to: lpoor2@email.uky.edu