Student Medical Incident Report

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Person Injured(Required):

This field is required.

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Include the type of person (staff, student or other) that was injured

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Specific location:

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Provide specific location (e.g.,

Involved Parties

Please provide as much information about the parties involved. For FVTC staff members, please provide an FVTC Staff ID number.

Name or Organization

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Address

Questions

Please describe the incident.(Required) This field is required.

Was external 911 Emergency Medical Services called?(Required)

Yes No

This field is required.

Was the injured party transported by ambulance?(Required)

Yes No

This field is required.

If the injured party was transported, please provide the name of the ambulance company and the name of the hospital, if known. This field is required.

Was further medical attention sought out by the injured party?(Required)

No Yes - The same day of the incident. Yes - In the days following the incident Unknown

You must make at least one selection.

If "Yes" to the question above, please explain (date of care, clinic or hospital used, etc). This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission