TCC Health Services
Incident Report
Date of Incident______/______/________ Time ___:___ am / pm
Name ____________________________ Phone (____)_________________
Colleague ID# _____________________ Date of birth ______/______/______ ( ) Male ( ) Female
Campus Incident location
Instructor/Sponsor _____________________________________ Campus ext.
Nature of incident: ( ) injury ( ) illness ( ) other
Please explain in detail _______________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Witness (es) ________________________________________________________________________
Date/time incident reported to:
Campus Police
____/____/______ _____:____ am / pm
Health Services
____/____/______ _____:____ am / pm
Initial first aid given on site, if any _______________________________________________________
__________________________________________________________________________________
(Check all that apply)
Referred to Health Services for evaluation/treatment or follow-up if after clinic hours.
Refused to go to Health Services (Signature of ill/injured)__________________________
________________ for self-care. Supplied bandage/cold pack (circle one) or other (describe)
Referred to personal physician.
___YES ___ EMS called: EMS transport NO
EMS recommended, party refused (Signature of ill/injured)
Disposition of student:
( ) Returned to Class ( ) Home ( ) Outside medical care
( ) Left campus by self ( ) Left campus with family or friend
Any additional comments:
Signature of person completing form _____________________________________________________________
Title _____________________________________________________ Date ____/____/________
TCCHS 07.15.15
Please complete and return this form to Health Services when an
injury or illness occurs on campus or at a College-sponsored event.
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