Injury Report Form

If this is an emergency, please dial 9-1-1

When an incident arises at the chapter causing bodily injury or property damage to any person, the following information must be obtained immediately. Do not withhold reporting an incident to obtain required information. Chapters are expected to submit this form within 24 hours of the incident.

Your submission is automatically sent to the National Office and is only shared with individuals directly involved in the incident, legal counsel and our insurance company.

Date of Incident *
Fraternity Entity/University involved in the incident (if applicable)
Injured Party's Name *
Injured Party's Email *
Injured Party's Phone *
Is the injured party an associate member or member of Alpha Psi Lambda? *

Where did the incident happen (if possible provide an address) *
Description of What Happened *
Include details on the nature of the injury
Was the individual taken to the hospital? *

Hospital Name
Witness 1 Name
Witness 1 Email
Witness 1 Phone
Witness 2 Name
Witness 2 Email
Witness 2 Phone
Attach any supporting documentation
Examples: Photos, Videos, Medical Information, etc.
Name of indiviudal submitting the report *
Position of individual subitting the report (if applicable)
Email of individual subitting report *
Phone of individual submitting report *