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Incident Report Form: Information About Person Involved in The Incident

This incident report form is used to document accidents, injuries, medical situations, or behavior incidents on campus. It requests information about the person involved such as their name, address, student/employee status, and contact details. It also requests details about the incident like the date, time, location, description of what happened, and whether witnesses or injuries were involved. The completed form should be submitted to the President's Office within 24 hours when possible.

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113 views2 pages

Incident Report Form: Information About Person Involved in The Incident

This incident report form is used to document accidents, injuries, medical situations, or behavior incidents on campus. It requests information about the person involved such as their name, address, student/employee status, and contact details. It also requests details about the incident like the date, time, location, description of what happened, and whether witnesses or injuries were involved. The completed form should be submitted to the President's Office within 24 hours when possible.

Uploaded by

Allehsiad Zenitram
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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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 Presidents Office.
INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT
Full Name
Home Address
Student
Phone Numbers

Employee

Visitor

Home

Vendor

Cell

INFORMATION ABOUT THE INCIDENT


Date of Incident

Time

Work

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


If yes, where was treatment provided:

No Refused
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 _________________________________

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FOR OFFICE USE ONLY


Document any follow-up action taken after receipt of the incident report.
Date

Action Taken

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By Whom

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