Share

Reporting an Incident That May Result in a Claim

In the event of an incident resulting in a bodily injury or property damage occurs during any Extension volunteer event or activity please complete an Incident Form. It is your responsibility to complete the form and to obtain the name, address and telephone number of witnesses to the incident. This responsibility also applies to the Extension staff who is involved in the event. Extension volunteers and staff are to refrain from discussing incidents that occur, but to report to Penn State's Risk Management Office. All legal correspondence associated with an incident should be reported immediately to the Risk Management Office. 

The following instructions should be followed when using the Incident Form. Copies of the instructions and report forms should be copied and given to volunteer leaders. 

Incident Report Form

Volunteer Leader Responsibility:

  1. Immediately, contact your county Extension Educator to report incident. 
  2. Complete incident form and turn into the County Extension Office within 24 hours. 

Extension Educator Responsibility:

  1. Immediately contact District Director. 
  2. Review incident report form to make sure all information is complete. 
  3. Send the original form to:
Peg Janowiak, Claims Specialist
Risk Management Office
227 W. Beaver Avenue, Suite 103
State College, PA 16801
Direct: 814-863-5539
Fax: 814-865-4029
Email: mxj4@psu.edu 

  4.  Send copy to:

Marilyn Corbin, FCS Program Leader
338 Ag Administration Building
University Park, PA 16802
Direct: 814-863-6109
Fax: 814-863-7776
Email: mac32@psu.edu

 

Clarification: If a police department or fire company did an investigation, include the name of the department or company, incident number and its address so that a copy of their report may be obtained if necessary.