DO NOT COMPLETE THIS FORM IF YOUR INJURY IS WORK RELATED. CONTACT HUMAN RESOURCES.
Last Name
Zip Code
State
City
Home Address
Injured First Name
Phone Number
Description of Accident
Date of accident/injury
Supervisor Name
Attach supporting documentation (i.e. Photos, Incident Report, Police Report)
Supervisor Contact Number
Location of accident
Number of documents attached
Full Name of Person Routing form:
Your form will be routed to the Office of
Risk Management for review.
If you require assistance completing this form please contact:
Charlene Waldorf, Director of Risk Management - 248.370.2725
Marisa Jurczak, Risk Management Coordinator - 248.370.4929
To complete processing - please be sure to click on the "Ok" in the pop up message once a button is clicked.
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Risk Management
Report On Campus Incident / Accident  Form 
ALL areas within a red border are required fields.

ALL areas within a red border are required fields.

Non-Auto Accident Only - Injured Person Information
Auto Accident Only - Driver/Vehicle Information
On-Campus Incident / Accident Report
Driver Last Name
Auto Insurance Company Name
Vehicle License Plate Number
Vehicle Model
Vehicle Make
Vehicle Year  
Zip Code
Zip Code
State
State
City
City
Insurance Address
Home Address
Driver First Name
Insurance Company Phone Number
Driver Phone Number
IF YOU HAVE QUESTIONS OR NEED ASSISTANCE COMPLETING THIS FORM CONTACT RISK MANAGEMENT AT RISKMGMT@OAKLAND.EDU.
Do not complete for Work Related Injuries.
This section populates once the Type of incident / accident radio button selection is made.
Email Address
Time of accident/injury
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