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
INFORMATION ABOUT THE INCIDENT
Date of Incident
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