Appendix N: Incident Report Form

INCIDENT DESCRIPTION:  
Name of 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?            Yes  No    

      If no, why not?  

      Did the student accept the offer to seek medical attention  Yes  No    

      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?          Yes  No  

      If no, why not?  

      Did the student accept the offer to contact authorities?  Yes  No    

      If no, 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 Education Abroad?  

      When?  

      How?  

2.  Who replied from Education Abroad?    

      When?  

      How?  

3.  Who reported the incident to student’s family or guardian?  

      When?  

      How? 

Follow up information should also include dates, times, persons contacted, actions taken, additional phone or contact numbers.  Append such notes to a final report, keep them on file and forward to Education Abroad.