Fillable COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT (Coastal Bend College)

Fill Online, Printable, Fillable, Blank COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT (Coastal Bend College) Form

Use Fill to complete blank online COASTAL BEND COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT (Coastal Bend College)

On average this form takes 60 minutes to complete

The COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT (Coastal Bend College) form is 3 pages long and contains:

  • 0 signatures
  • 93 check-boxes
  • 198 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Coastal Bend College

BROWSE COASTAL BEND COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT
1 | P a g e
REPORTING PERSON
Full Name
CBC EMPLOYEE?
Yes No
Home Address (not necessary for CBC employees)
Campus resident
Yes No
Student ID number
Are you a:
Student
Yes No
Visitor
Yes No
Vendor
Yes No
Phone Numbers
Home
Cell
Work
INFORMATION ABOUT PERSON INVOLVED OR IS A WITNESS
Full Name
CBC EMPLOYEE?
Yes No
Home Address (not necessary for CBC employees)
Campus resident?
Yes No
Student ID number
Is this person a;
Student
Yes No
Visitor
Yes No
Vendor
Yes No
Phone Numbers
Home
Cell
Work
INFORMATION ABOUT PERSON INVOLVED OR IS A WITNESS
Full Name
CBC EMPLOYEE?
Yes No
Home Address (not necessary for CBC employees)
Campus resident?
Yes No
Student ID number
Is this person a;
Student
Yes No
Visitor
Yes No
Vendor
Yes No
Phone Numbers
Home
Cell
Work
INFORMATION ABOUT PERSON INVOLVED OR IS A WITNESS
Full Name
CBC EMPLOYEE?
Yes No
Home Address (not necessary for CBC employees)
Campus resident?
Yes No
Student ID number
Is this person a;
Student
Yes No
Visitor
Yes No
Vendor
Yes No
Phone Numbers
Home
Cell
Work
INSTRUCTIONS: This report form should normally be completed by a CBC employee, but may be completed by any
person with sufficient knowledge of the incident, injury, or issue being reported. If completed by a CBC employee, the
report shall be typed and signed and either scanned or sent via college mail system to the CBC Director of Public Safety.
Use this form to report safety concerns, accidents, injuries, emergency medical situations, suspicious persons or
activities, and criminal acts that OCCUR on CBC PROPERTY. Please note that incidents involving a crime or traffic
incident should be reported directly to the Police and then to the Site Director if the incident or injury did not
occur on the Beeville CBC Site. The CBC Director of Public Safety should be contacted for issues that occur at the Beeville
site. Site Directors or the reporting employee’s supervisor should provide an incident report to the CBC Department of Public Safety as
soon as practical. This report should normally be completed within 24 hours of the event.
Submit completed report to the CBC Department of Public Safety on the Beeville Campus, ATTENTION - DIRECTOR OF
PUBLIC SAFETY.
NOTE: If your complaint concerns a Student Conduct or Title IX issue or incident, please follow the hyperlink to the
appropriate reporting page or access information at http://coastalbend.edu/StudentRightsResponsibilities/ for student
complaints or conduct issues. To report a Title IX concern or complaint, access http://coastalbend.edu/titleix/.
CATEGORY OF REPORT (you check as many selections as apply)
Criminal
Complaint
Disruptive
Behavior
Suspicious
Activity/Person
Safety Issue/
concern
Injury on
CBC Property
Damage to
CBC Property
COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT
2 | P a g e
REPORTER INFORMATION
Individual Submitting Report (print name)
Signature
Date Report Completed
INFORMATION ABOUT THE INCIDENT
Day and Date of Incident
Time
Did this incident require that Police or EMS be Notified? Yes* No
*If your response is YES complete Police Related section below
Identify the CBC site involved in this report: Beeville Alice Kingsville Pleasanton
Other Identify Specific Location of Incident or issue: ________________________________________________________________________________
Description of Incident: In your written description of the events and/or details of the incident or issue. Be as specific and detailed as possible by documenting
Who is involved, What happened, When did it happen, Where did it happen, Why did it happen, and How did it happen, in this section of the report.
(attach
additional sheets if necessary)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_________________________________________________________________________________________________ ______
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
EMS related issues
Was EMS called to your site? Yes No
Did it involve medical treatment of an EMPLOYEE? Yes No
Did it involve medical treatment of a STUDENT? Yes No
Was medical treatment provided? Yes No Refused
If yes, where was treatment provided: on site
 Urgent Care
 Emergency Room
 Other
Was person transported a student? Yes No
Was person transported an employee? Yes No
Where was patient transported? ________________________
If this is an injury, was it caused by an assault? Yes No
Police related issues
Were Police called to your site? Yes
No
Was an incident report made by on-scene police? Yes
No
Identify the primary police agency who investigated the
issue or incident __________________________________
Did you receive an incident number from police officers at
the scene? Yes No
List number _____________________________________
Was a custodial arrest made by police officers on CBC
premises? Yes No
IF someone was injured, please describe the injury (laceration, sprain, etc.)
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
✔
COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT
3 | P a g e
CBC DEPARTMENT OF PUBLIC SAFETY OFFICE USE ONLY
FOLLOWUP TRACKING
Document any follow-up action taken after receipt of the incident report.
INTAKE
Date
Action
Taken
By Whom
CLERY REPORTING REQUIRED?
Yes No
REPORTED ON DAILY SECURITY REPORT?
Yes No
DATE ENTERED ONTO CBC SECURITY DAILY REPORT
Date:
Time:
Rec by:
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

COASTAL BEND COLLEGE INCIDENT, SAFETY, OR INJURY REPORT (Coastal Bend College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 5 October 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document