Location Kaiserslautern - RPTU Rheinland-Pfälzische Technische Universität Kaiserslautern-Landau

Fields marked with an asterisk(*) are mandatory

Details of the injured person

Lastname of the injured person:*

First name of injured person:*

Date of birth:*

Email:*

Telephone number:*

Status of the injured:*

Organizational unit/Department/Division/Working group:*

Head of Department/Head of the working group:*

Details of the accident

Category of accident:*

Date of the accident:*

Time of the accident, hh:mm:*

Scene of the accident, Building/Room/Floor/Street/City:*

Type and extent of injury (left, right, which part of the body, wound...):*

Detailed description of the accident:*

Doctor's visit required:*

Name, VoLast name, first name of a witness or who was first informed about the accident at the RPTU?:

Last name, first name of the first responder, if available:

Method of providing first aid: