Accident/Incident Report

Please fill out and submit this form within 24 hours of the occurrence. Note that you must enter a response in each field (even if it is "n/a" or "unknown") or the form will fail. When you have successfully submitted the form,  please print out and sign the confirmation page, and submit the signed confirmation to the Health Services Office. Thank you!

(* indicates required field)

*Name of person involved:
 
 (First name)
 
 (Last name)
*Date & time
of occurrence:
 
  (Date) 
 
 (Time)
      
*Location of occurrence:  
    
  *Witnesses:    
*Detailed description
of occurrence:		  
 Describe how accident/incident occurred, any mechanism involved
  
*Assessment of injury:
 
*Response:  
 Describe treatment administered. Detail whom, how, when and where.
 
*Transportation:  
 If injured party was transported for further assessment/treatment, who did the transporting?
 
*Notification:

 
 Name of parent/designated emergency party notified:
 
 

  Time of notification:
 
*Submitted by:  Your name