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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
Student
Phone Numbers

Employee

Visitor

Home

INFORMATION ABOUT THE INCIDENT
Date of Incident

Cell

Time

Vendor
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, an