Skip to Content - Skip to Navigation

IUP Student or Visitor Injury Report

Complete this form when an injury is sustained on university property. No claim can be provided to the Bureau of Risk Management without a completed injury report. E-mail questions to studentorvisitor-injury-report@iup.edu.

Information about the Person Injured

 

 

 


 


 

(Permanent)
 

(Optional)
 


 

 

 
Gender
        
Birth Date

 

,

 
Reason for being on campus:
        


 

If you marked student:
       

(Local)
 

(Optional)
 


 

 

 


 

If you marked Conducting Business:



 


 

(Optional)
 


 

 

 
Date and Location of Injury

 

,

 

(Be specific, i.e. building name, street, etc.)
 

(Be specific. If using tools, equipment, or handling material, name them and tell what he/she was doing with them.)
 

(Describe fully the events that resulted in injury. Name any objects or substances involved and tell how they were involved. Give full details on all factors which led or contributed to the injury.)
 


 

Treatment
        
Medical Expenses Incurred
  1. (Please provide copy to the University Police Administrative Assistant)
       
Person Completing Form

  1. (Note: You will still be required to provide your email address below even if the mailing address is the same.)
       

*Required
 


 

 

 


 


 

(Optional)
 


 

 

 
Release of Information
  1. When you submit this report, you are releasing all information pertaining to the injury to the University Safety Department.
        

 

  • University Police
  • University Towers
    850 Maple Street
    Indiana, PA 15705
  • Phone: 724-357-2141
  • Fax: 724-357-2104
  • Office Hours
  • 24 hours a day, 7 days a week