Medical Incident Form

Submit - Adult Medical Incident Report

First Name of Injured Person: *

Last Name of Injured Person: *

Date of Incident: *

Time of Incident *

Campus *

Description of Incident: *

How did the incident happen? *

Where in the building did it happen? *

Describe the area of the person's body that was injured: *

Was first aid given or some other action taken? *

Yes

By Whom: *

Describe action taken: *

How did the person respond after the incident? *

Did anyone witness the incident?

Yes

Name of Witness(es) *

Name of Volunteer or Staff Supervising area: *

Signature of person completing this form: *

Print Name *

Person completing this form

Email *

Signature of Witness *

Print Name *

Witness

Email *

Todays Date & Time

If you are human, leave this field blank.