Student Injury/Illness Incident Report Form

Name of person reporting incident:
Date:
Time of accident:



Campus:    Battery Park   26 Broadway

Type of Injury:

The injured person(s) is a:
   Student   Staff   Instructor

Location of Incident (course and room number):

Name(s) of Person(s) injured:


Describe exactly what happened:


Emergency medical treatment given? Yes No
      To whom?
      By whom?
      Describe procedure(s):

EMT or Police called to the scene? Yes No
      Name of police department or EMT:

Person(s) taken to hospital? Yes No
      Name(s):
      Name of hospital:






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