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Project Friendship Accident/Incident Report

Use this form to report accidents, injuries, medical situations, criminal activities, or student behavior incidents. If possible, a report should be completed within 24 hours of the event.

1. Date of Report: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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2. Mentor's full name *This question is required.

3. College mentor attends: *This question is required.

4. Date of Incident: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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5. Time of Incident: *This question is required.

6. Where did the incident take place? Please be as specific as possible. For example, if incident happened on campus, please state building and room number if possible. *This question is required.

7. Describe the incident and the events leading up to the incident. Please be as specific as possible. *This question is required.

8. Was anyone injured? *This question is required.

9. If yes, please describe the injuries.

10. Name(s) of injured persons.

11. Were there witnesses to the incident? *This question is required.

12. If yes, please enter the witnesses' names and contact information.

13. Were police, emergency medical services, or campus security notified? *This question is required.

14. If yes, was a report filed?

15. Was medical treatment provided? (Either by Mentor, police, EMS, or someone else? *This question is required.

16. If medical treatment was provided, WHERE was the medical treatment provided?

Please enter an 'other' value for this selection.

17. Please describe the type of medical treatment provided and who provided the medical treatment.
For example - ice pack, band aid, CPR, splint, etc. - provided by front desk employee.
**Please be specific.