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Nursing Student Incident Report
Date/time of incident ______________________________________
Student name ____________________________________________
Course number and title in which incident occurred ____________________________________________
Exact location of incident ________________________________________________________________
Nature of incident ___________________________________________________________________________________
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Action taken and by whom ____________________________________________________________________________
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Medical attention given, if needed _______________________________________________________________________
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Signature of person making report _______________________________________________________________________
Date submitted __________________________________________
NOTE: Course coordinator to keep one copy and send one copy to associate dean for program in which student is enrolled
(to be placed in student’s file in 315 CON Student Services).
Approved by Coordinating Council 1/10/11