Lambda Chi Alpha - Collegiate

Risk Management

Chapter:
Date of Incident:
Time:
Person Involved:
Position/Affiliation:
Employee?	Yes No
Supervisor Name:
Length of time employed:
Was Injury involved in task/job/other:
Did the Incident result in injury?	Yes No

Nature and extent of injury:

Date injury reported:
Was first aid given?	Yes No
Reported to General Fraternity?	Yes No
Date Reported:
If so, by whom?
General fraternity Staff Contact:

Timeline of Events:

Location of Incident:

Date of this report:
Signed (your name):
Title: