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University of Virginia Office of Risk Management

Summary: University of Virginia
Office of Risk Management
Incident Report Form
Complete this form to report any non-auto related incident resulting in potential bodily injury or property damage/loss /theft of
University property.* Incident Report Forms are available at www.virginia.edu/riskmanagement. Please contact the University Claims
Adjuster at 434-924-3055 if you have questions. Send the completed form within 24 hours of the incident to Risk Management by:
Facsimile Messenger Mail or USPS Courier
Office of Risk Management
P.O. Box 400205
Charlottesville, VA 22904-4205
2400 Old Ivy Road
Suite 181
Time and date of incident:
Specific location of incident (street, building, room, etc.)
Description of incident: Explain in detail the manner in which the incident or loss occurred. Please state the conditions present at the
time of loss (e.g., weather, construction, cleaning). Use additional pages if more space is needed.
Were University of Virginia police notified?
If so, provide the date police were notified:
For potential bodily injury cases, give the name, address, and phone numbers of the injured party:


Source: Acton, Scott - Department of Electrical and Computer Engineering, University of Virginia


Collections: Computer Technologies and Information Sciences