CC- Incident Report

Incident Report
An Incident Report is completed when any unusual event or circumstance that a student is involved in.

In addition to the verbal notification required, all incidents must also be documented within forty-eight (48) hours of occurrence using this form.
Campus*
Program Name*
Start Date*
Student Name*

First NameLast Name
E-mail Address*
Location of the Incident:*
Name of Individual(s) Involved:*
Date of the Incident:*

MonthDayYear
DateHourMinutesAM/PM Option
Description of the Incident:*
Witnesses to the Incident:*
Did an Injury Occur:*

YesNo
If Yes, was Treatment Rendered if Necessary or Refusal of Care Statement:
Supporting Documentation:

Supporting documentation must be a scanned PDF, Microsoft Word or Microsoft Excel document, NOT a picture. For a free scanning app for your phone click the link below:

https://acrobat.adobe.com/us/en/acrobat/mobile-app/scan-documents.html
Supporting Documentation (if applicable)

Upload a File

Cancelof
Name of Person Completing Report:*

First NameLast Name
Signature*

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