Non Work Related Injury Form Template - Fill Online, Printable 2026

1. Click ‘Get Form’ to open the Non Work Related Injury Form Template in our editor.
2. Begin by filling in the 'Name of Injured' field along with their 'Age', 'Address', and 'Telephone'. Ensure all personal information is accurate for effective processing.
3. Select the appropriate 'Gender Identity' and 'Status' (Student, Employee, Visitor) to categorize the injured party correctly.
4. Record the 'Date of Accident' and 'Time of Day'. This information is crucial for documentation purposes.
5. Provide details about the person in charge of the area or activity at the time of the accident. Indicate whether UC Police were called and if transportation to a hospital was necessary.
6. In the 'DETAILS OF ACCIDENT' section, describe fully what happened, including location, circumstances, and any contributing factors.
7. Detail the nature of the injury in the 'DESCRIPTION OF INJURY' section, specifying which part of the body was affected.
8. Indicate any first aid measures taken prior to medical treatment in the 'DESCRIPTION OF ASSISTANCE RENDERED' section.
9. Complete the report by filling in your department name, your details as preparer, and ensure it is reviewed by a department representative before submission.

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