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Accident Report
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* Indicates required question
Date
*
MM
/
DD
/
YYYY
Time of Injury
*
Time
:
AM
PM
Name of Injured Person
*
Your answer
Age
*
Your answer
Telephone Number
*
Your answer
Are you a Stony Brook University Student?
*
Yes
No
If above question is no, then write the school you attend on the line below or N/A if not applicable
*
Your answer
Stony Brook ID Number (write N/A if not applicable)
*
Your answer
Which department did this occur in?
*
Operations - Marlene Kasman
Intramurals/Sports Clubs - Wyatt Cushman
Fitness/Wellness - Erin Maurno
Pool - Erin Maurno
Challenge Course - Marie Turchiano
Location of Injury (Body)
*
Your answer
Cause of Injury/Accident Description (please include the names of individuals involved, nature of incident, names & addresses of witnesses, and narrative of what occurred)
*
Your answer
Condition of Injured Area
*
Redness
Swelling
Discoloration
Heat
Deformity
Bleeding
Unwillingness to move
Other:
Required
Did the injured person refuse any professional or medical attention?
*
Yes
No
Action taken on behalf of injured person while on premises?
*
Your answer
Provider of Medical Treatment?
*
Your answer
Police / Ambulance Called?
*
Yes
No
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