Environmental Health & Safety Incident Report Form

The Environmental Health and Safety Incident Report Form is used to report incidents that result in injury, property damage or casualties at 缅北禁地 University that may require involvement from our Environmental Health and Safety (EHS) Team.

This form helps 缅北禁地 University identify risks and respond to potential claims or safety hazards, and is available for both employees and non-employees at 缅北禁地 University. Our incident form covers a wide range of incidents, including but not limited to:

environmental health concerns
facility or property damage
vehicle accidents involving a university vehicle
work-related injuries
chemical exposure or contact with hazardous materials

The form may also relate to incidents where liability claims could be made against the university. For further details regarding insurance and liability claims, please refer to our Insurance page.

Please note that Title IX, discrimination-related incidents, and criminal matters are not reported through this form. For such incidents, you should contact the appropriate university departments, such as Title IX or the 缅北禁地 University Police Department (TUPD).

1. Please Provide The Following Contact and Incident Information:

Victim鈥檚 Name (Firm Name if Business) Last, First, Middle

TU ID #, if applicable

Address, City, State, Zip Code

Phone

Employer/School or Local Address

Employer/School or Local Phone Number

Incident/Narrative

Date and Time Occurred

AM /PM

AMPM

Location of Incident Address

Hospitalized?

YesNo

Transported to Hospital?

YesNo

Hospital Name

Transported By

Injuries/Illness Sustained

Work Related?

YesNo

2. Additional Information/Witnesses

Name #1 (Last, First, Middle)

Address, City, State, Zip Code

Home Phone

Business Phone

Name #2 (Last, First, Middle)

Address, City, State, Zip Code

Home Phone

Business Phone

EHS Contact Information: 缅北禁地 University, Department of Environmental Health & Safety, 8000 York Road, 缅北禁地, MD 21252. Phone: 410-704-2949, Fax: 410-704-2993. For information on how to file a claim with the State Treasurer鈥檚 Office, contact the Insurance Administrator at 410-704-6377.

Depending on the request, EHS and/or the Insurance Administrator may contact you with further instructions or schedule a date and time for assistance.