NOTICE OF INCIDENT
(Record Only)
Revised: 06/01/07
This form must be completed when a claim is not expected for personal injury or
property damage. It is for record only and should be completed as soon as
practical after the occurrence, but within ninety (90) days of the occurrence.
File the form with:
Department of Safety and Risk
Services
1801 Tucker St. NE, Bldg 233 MSC07 4100
1 University of New Mexico
Albuquerque, New Mexico 87131-0001
Full Name____________________________ Phone No(s)___________________________________________________________________
__________________________________________________________________________________________________________________
Mailing Address (Include city, state, zip code)
Amount of damages (if known) $________
Describe WHERE, WHEN, and HOW the damages or injury occurred. Include names of
all persons involved and any witnesses, including their addresses and telephone
numbers.
Location of the Occurrence: ___________________________________________
Date of Occurrence:_____________ Approximate Time:_____________
Description of the
Occurrence:__________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Describe the injury or damage you sustained and attach copies of all medical
reports, bills, or estimates of
repairs.__________________________________________________________
____________________________________________________________________________________
All of the statements made on this form are true and correct to the best of my
knowledge.
Date ______________ Signature of Person
Reporting___________________________________________
Daytime Phone No. ________________________
Comments
may be sent to UBPPM@UNM.edu
http://www.unm.edu/~ubppm