Campus Incidents Students, Contractors and Guests

Instructions:

Please complete all sections of this form to the best of your ability. Provide as much detail as possible to ensure a thorough review of the incident.
Attach any supporting documentation, such as photos, videos, or relevant records, if available.
This report will be treated with the utmost confidentiality and will only be shared with authorized personnel involved in addressing the incident.

Note: False or misleading information may result in disciplinary action.

Reporters Information

Person Type

Public

How are you affiliated with the University

Staff

Faculty

Student-Staff

Student

Guest or Public

Contractor

JCI or JCI Subcontractor

User filling in form (You)

Person Injured/Affected Supervisor Witness / Person Reported To (Other Students, Visitor) Other

Incident General Information

What Type of Incident or Severity

Incident only (e.g., near-miss, minor injury, property damage)

First Aid

Time loss (e.g., days off work, excluding incident day)

Medical Treatment (e.g., visit doctor, no days off)

Other

Date and Time of Incident:

Incident Location

Description of Incident Location

Please do not include personal information such as names, gender pronouns and medical information.

Involved Parties

Number of People Involved:

List the Involved Parties including any Witness(s)

Provide details of individuals involved in incident, including their full names and contact information if available.

Incident Description

Incident Title

Please give this incident a short title (please do not include personal information such as names, gender pronouns and medical information)

Description of the Incident:

Provide Detailed Account of the Incident, include:
- Sequence of events
- What happened, how, and why (if known)

Actions Taken at the Time of the Incident:

Provide What Actions were Taken at the Time of the Incident:
- Who responded and what actions were taken (e.g., first aid, reporting to campus security)

Supporting Documentation

Please attach all supporting documents, photos and reports.

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Your name

Your email address

Your phone number

Verification Code