Incident Report Form for Faculty-Led Programs
Western Carolina University, Office of International Programs and Services
INCIDENT DESCRIPTION
Name of Faculty-Led Program:______________________________________________Today’s Date:___________________
Time, Date of Incident/Accident: __________________________________________________________________________
Location of Incident (be very specific):______________________________________________________________________
Name of Student(s) Involved: _____________________________________________________________________________
Nature of Incident: ______________________________________________________________________________________
_____________________________________________________________________________________________________
_______________________________________________________________
______________________________________
1.
How, when and from whom did you hear about the incident?__________________________________________________
__________________________________________________________________________________________________
2.
Was medical attention offered to the student? If no, why not?__________________________________________________
___________________________________________________________________________________________________
If yes, did the s
tudent accept
the
offer
to
seek
medical
attention?
if no, why not?___________________________________
___________________________________________________________________________________________________
If yes, where was the student taken? (name and address of hospital and attending physician): What was the result?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
3.
Was the student offered assistance or encouraged to report the incident to local or international authorities?
If not, why not? ______________________________________________________________________________________
If yes, what office was contacted? (name and address of police station or consulate): What was the result?
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
COMMUNICATION:
1.
Who reported the incident to Office of International Programs and Services? When and How?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
2.
Who replied from IPS? When and How?
__________________________________________________________________________________________________
________________________________________________________________________________________________
3.
Who reported the incident to student’s family or guardian? When and How?
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Courtesty to Indiana University Office of Overseas Studies
