Fillable Instructions: College employees/students/guest are to complete this form (Eastern Shore Community College)

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Instructions: College employees/students/guest are to complete this form (Eastern Shore Community College)

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INCIDENT FORM
Instructions: College employees/students/guest are to complete this form as a written record of any reported incident occurring on campus. An incident is defined as
any occurrence related to personal health or safety (e.g., accident, injury, or illness), any occurrence related to criminal activity (e.g., theft, assault), or any
occurrence related to property damage (e.g., flood, explosion). Return/email completed forms to the Campus Security Department.
First Name:
Middle Initial:
Last Name:
EMPLID:
DOB:
Social Security Number (optional):
Current Mailing Address:
Email:
City:
County:
State:
Primary phone:
Alternate Phone:
Secondary Contact Name:
Phone:
Relationship:
Date of Incident? ________
Time of Incident? ________
Location in Which Incident Occurred?
Type of Incident:
Accident:
Criminal Activity:
Personal Property Damage:
College Property Damage:
Illness:
Injury:
List the Names, Address, and Telephone Numbers of All Persons Involved:
Other:
Notified:
Law Enforcement:
Fire Department:
Ambulance:
Utility Company:
State Agency:
No Authority Notified:
If other, please explain:
List the Names, Address, and Telephone Numbers of Any Witnesses:
Describe the Incident
Needs Identified:
Action Plan (Campus Security/Police Use Only):
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Instructions: College employeesstudentsguest are to complete this form (Eastern Shore Community College)

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Completed 27 July 2020

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