Incident Report

Incident Reported by:*
First Last
Email*
Date of Incident*
MM slash DD slash YYYY
Approximate Time of Incident*

: Hours

Minutes

AM/PM
Campus*
Department*
Describe the Incident*
Describe any first aid or medical treatment provided.
Was anyone admitted as a patient or kept overnight at the hospital?*
- No
- Yes
What follow-up has been done or will be done by staff?*
Was there any property damage?
- No
- Yes
Describe the property damage.
What might be done to prevent or prepare for incidents of this nature in the future?