PDF Incident Report Form
Incident Report Form
Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a crime or traffic incident should be reported directly to the Campus Public Safety office.) If possible, the report should be completed within 24 hours of the event. Submit completed forms to the President's Office.
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name
Home Address
Student
Employee
Visitor
Phone Numbers Home
Cell
Vendor Work
INFORMATION ABOUT THE INCIDENT
Date of Incident
Time
Police Notified Yes No
Location of Incident
Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible (attached additional sheets if necessary)
Were there any witnesses to the incident? Yes No If yes, attach separate sheet with names, addresses, and phone numbers. Was the individual injured? If so, describe the injury (laceration, sprain, etc.), the part of body injured, and any other information known about the resulting injury(ies).
Was medical treatment provided? Yes No Refused
If yes, where was treatment provided: on site
Urgent Care Emergency Room
Other
REPORTER INFORMATION Individual Submitting Report (print name) Signature Date Report Completed
FOR OFFICE USE ONLY
Report Received by __________________________________________________
Date _________________________________
FOR OFFICE USE ONLY Document any follow-up action taken after receipt of the incident report.
Date
Action Taken
By Whom
................
................
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