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Report Fall or Injury
Report Fall or Injury
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Are you a MassArt employee or student?
Employee
Student
Student employee
Non member of community
Other
MassArt ID number
Name of person injured
Department of injured party
Job title of injured party
Title
A short description to explain the nature of a ticket.
Describe your injury, what led up to it and what happened.
The full details of a ticket, including any appropriate circumstances or supplementary information that may aid in resolving it.
Press Alt + 0 within the editor to access accessibility instructions, or press Alt + F10 to access the menu.
What date did the injury or fall occur
(mm/dd/yyyy)
What time did the injury occur?
Why did this happen?
Examples could be, unsafe lighting, uneven ground,
Where did this happen?
Artists' Residence
Collins
Design and Media Center
East
Kennedy
North
Smith Hall
South
Tower
Tree House
Outside
Unknown
Closest room are area
Location Type
What type of space is this location ie: classroom, office, studio etc
Classroom
Lab/Workspace
Studio
Office
Hallway or Corridor
Walkway/Ramp
Outdoors
Restroom
Elevator
Other unlisted
Was the injured party working at the time of the incident?
yes
no
non employee
Severity of the injury
Severity of the injury
1- Negligible
2
3
4
5- Emergency situation
Did the injured party require medical attention?
No
Yes
Best phone number to reach the person completing form
In the event we need to schedule a consultation, get more information or reach out for any other reason, please enter the best phone number and time to reach you.
Phone number of injured person
In the event we need to schedule a consultation, get more information or reach out for any other reason, please enter the best phone number and time to reach you.
Attachment
File attachments associated with the ticket.
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Other Fields
Your name
Your first name
Your last name
Your email address
Verification Code