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    Assg Incidentreportform 20180122 Ah102

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    api-393314541
    This incident report form is used to document any accidents, injuries, medical issues, or behavior incidents on campus. It requests information about the individual involved, details of the incident including location, description, witnesses, injuries, and treatment. The completed form should be submitted to the President's Office within 24 hours for documentation and any necessary follow-up actions.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Assg Incidentreportform 20180122 Ah102

    Uploaded by

    api-393314541
    19 views2 pages
    This incident report form is used to document any accidents, injuries, medical issues, or behavior incidents on campus. It requests information about the individual involved, details of the incident including location, description, witnesses, injuries, and treatment. The completed form should be submitted to the President's Office within 24 hours for documentation and any necessary follow-up actions.

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    assg incidentreportform 20180122 ah102

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    This incident report form is used to document any accidents, injuries, medical issues, or behavior incidents on campus. It requests information about the individual involved, details of the incident including location, description, witnesses, injuries, and treatment. The completed form should be submitted to the President's Office within 24 hours for documentation and any necessary follow-up actions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    19 views2 pages

    Assg Incidentreportform 20180122 Ah102

    Uploaded by

    api-393314541
    This incident report form is used to document any accidents, injuries, medical issues, or behavior incidents on campus. It requests information about the individual involved, details of the incident including location, description, witnesses, injuries, and treatment. The completed form should be submitted to the President's Office within 24 hours for documentation and any necessary follow-up actions.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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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 President’s Office.

    INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT


    Full Name
    Home Address
    D Student D Employee D Visitor D 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

    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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