Illness, Injury & Accident Report

BACKGROUND INFORMATION

Please complete the background information below to help us respond accordingly.

Your full name:

Your position/title at DACC:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Urgency of this report(Required):

This field is required.

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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Please provide additional location information if applicable.

INVOLVED PARTIES & WITNESSES

Please note all parties involved including witnesses.

Name of Person Involved

Select Gender

Select Role

DOB (YYYY-MM-DD)

Phone number

Email address

QUESTIONS

Please complete the questions below to help us promptly follow up with the report and individuals involved.

Please provide a detailed description of the circumstances involved with the injury/illness/accident.(Required) This field is required.

Who was the first person to respond?(Required) This field is required.

What type of care was given?(Required) This field is required.

Did the injured/ill person make any statements about the event or their condition?(Required) This field is required.

Was an ambulance called?(Required) This field is required.

Was the individual transported by the ambulance?(Required) This field is required.

Does the injured/ill person have any known allergies or pertinent diagnosis? This field is required.

Who is the nearest relative of the injured/ill individual? What is the best way to contact him/her? This field is required.

SUPPORTING DOCUMENTATION

Please provide any documents or evidence that would be relevant to this report. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

DACC OFFICIALS TO COPY

Please select the DACC Officials you would like cc'd in regard to this report.

Chief of Safety & Security - Mr. Nathan Howie

Assistant Vice President of Student Services - Brian Hensgen

Safety & Security Officer - Mr. Cliff Hegg

Safety & Security Officer - Mr. Dylan Miller

Provost and Vice President of Academic Affairs / Student Services

Email me a copy of this report

BACKGROUND INFORMATION

INVOLVED PARTIES & WITNESSES

QUESTIONS

SUPPORTING DOCUMENTATION

DACC OFFICIALS TO COPY

Submission