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PO BOX 712 Goose Creek, SC 29445

+1 833-655-0069

INCIDENT REPORT

Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or student behavior incidents. If possible, a report should be completed within 24 hours of the event.

Date of Report *

Person Involved

Full Name

Address

City

State

Zip code

ID #

Phone *

Email *

The Incident

Date of Incident

Time of Incident

Location of Incident

Describe The Incident

Injuries

Was Anyone Injured?

Yes

No

If Yes, Describe the Injuries

Witnesses

Was There a Witnesses

Yes

No

First Name

Last Name

Phone Number

Email Address

Additional Comments

Police & Medical Services

Was the Police Notified?

Yes

No

If Yes, Was a Report Filed?

Yes

No

Report Number

Was Medical Treatment Provided?

Yes

No

Did You Refuse Treatment?

Yes

No

Where Were You Treated?

Where Were You Treated?

On Site
Hospital
Other
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Additional Comments 1

Person Filing Report

Signature

Clear

Print Name

Date Signed

FOR OFFICE USE ONLY

Report Received By

First

Last

Date Received

Follow Up Action Taken

Signature

Clear

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