Health and Safety Incident Report Form

This form is not intended for use in emergency situations. If this is an emergency, please contact local staff at your host institution and/ or local police.

If you are a student, please write "student."
Please list general area/building/neighborhood or street address where incident took place.
Involved Parties. Please enter as many as were present or involved at the time of the incident.
List the name of the Education Abroad program in which the involved student was participating.
List the country of the Education Abroad program in which the involved student was participating.
Please describe the nature of the incident in as much details as possible. Details regarding the location and activities leading up to the incident are helpful. If you are reporting an illness or injury, provide an explanation of the affected area and description of the symptoms
Name and address of doctor and hospital
Photos, video, email, and other supporting documents may be attached below. Attachments require time to upload, so please be patient after submitting this form.

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