HTML Preview Medical Office Incident Report page number 1.
Report Received by __________________________________________________ Date _________________________________
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 Vendor
Phone Numbers Home Cell 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