Injury Report NAME OF INDIVIDUAL COMPLETING FORM* First Last EMAIL OF INDIVIDUAL COMPLETING THE FORM* Location*The location where the injury/incident took placeDate* MM slash DD slash YYYY DATE OF INCIDENTTime*TIME OF INCIDENT : Hours Minutes AM PM AM/PM ACTIVITY TYPE*Open RecreationIntramural SportsSport ClubsGroup-X ClassSport and Rec ClassOutdoor Pursuits ProgrammingUREC CourseOther/please include this in the full description portionFULL DESCRIPTION & CAUSE OF INCIDENT*NAME OF PERSON INJURED* First Last STUDENT/STAFF UWM ID NUMBERXXX-XX-XXXXAddress*ADDRESS OF PERSON INJURED Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*PHONE# OF PERSON INJUREDNATURE AND EXTENT OF INJURIES*DESCRIPTION OF PROPERTY DAMAGED:SIGNATURE OF THE INDIVIDUAL FILLING OUT THE FORM*