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    This incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. It requests information about the person involved, including name, address, and contact details. It also requests details about the incident, including date, time, location, description of what happened, any witnesses, injuries sustained, and medical treatment received. The completed form should be submitted to the President's Office within 24 hours of the incident.

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    Chei

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    This incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. It requests information about the person involved, including name, address, and contact details. It also requests details about the incident, including date, time, location, description of what happened, any witnesses, injuries sustained, and medical treatment received. The completed form should be submitted to the President's Office within 24 hours of the incident.

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    This incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. It requests information about the person involved, including name, address, and contact details. It also requests details about the incident, including date, time, location, description of what happened, any witnesses, injuries sustained, and medical treatment received. The completed form should be submitted to the President's Office within 24 hours of the incident.

    Copyright:

    © All Rights Reserved
    Download as ODT, PDF, TXT or read online from Scribd
    Download as odt, pdf, or txt
    30 views3 pages

    Chei

    Uploaded by

    api-389332081
    This incident report form is used to document accidents, injuries, medical situations, or behavior incidents involving students or employees. It requests information about the person involved, including name, address, and contact details. It also requests details about the incident, including date, time, location, description of what happened, any witnesses, injuries sustained, and medical treatment received. The completed form should be submitted to the President's Office within 24 hours of the incident.

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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
    Lizbeth White
    123 loe rios street
    D Student D Employee D Visitor D Vendor
    Phone Numbers Home Cell (435)434-6847 Work

    INFORMATION ABOUT THE INCIDENT


    Date of Incident Time Police ◻Y ◻ No
    12/28/2013 8:23pm Notified e
    s
    Location of Incident
    Home

    Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible
    (attached additional sheets if necessary)

    She was running outside when she stepped wrong and twisted her ankle. Ankle is has been swollen for almost 4 days and
    hurts to walk on the left leg.

    Were there any witnesses to the incident? ◻ Yes (x) 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).

    Ankle is swollen from the left leg.

    Was medical treatment provided? ◻ (x) No ◻ Refused


    Yes If yes, where was treatment ◻ on site ◻ Urgent ◻ Emergency ◻ Other
    provided: Care Room

    REPORTER INFORMATION
    Individual Submitting Report (print name)

    Signature

    Date Report Completed


    FOR OFFICE USE ONLY

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

    Date Action Taken By Whom

    By completing this chef complaint it shows me how important this


    document can be and how to properly fill out the complaint.

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