Risk Management Form Accident-Incident Report International Travel & Study Abroad FORM 5 Date of Incident and Time of Incident: _______________________________ Emergency Contact Name: __________________________ Name of Claimant: ______________________________ Address: ______________________________________ Primary Phone #: __________________ State/Zip Code: ________________________________ Relationship: _____________________ Employee ______ Student _______ Contact Notified? Yes_____ No_____ Date/Time: ______________________ ID#: __________________________________________ NOTIFY SECURITY IMMEDIATELY! Indicate below which College Security Office was contacted to report the incident, who you spoke to, and date/time of reporting. Contact your campus Security Office during normal work hours. Contact the Lake Worth Security Office (#01-561-868-3600) at all other times (24/7) or if contact cannot be made with your campus Security Office. Describe all circumstances of accident/incident and all action taken: _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ Your Name & Title of Reporter: __________________________________________________ Date: _____________ Time: _____________ Sample incident report: Palm Beach State College International Travel & Study Abroad Guide Accident-Incident Report Place, Date of Incident and Time of Incident: 01/01/12 - 9:00 a.m. local time (London) Hotel_____Room #123A Name of Claimant: James Jones Address: 123 Oak Street, State/Zip Code: Lake Worth, FL 33461 Employee ______ Student __X ID#: J1234567 Emergency Contact: Name: Mrs. James Jones Sr. Primary Phone #: 561-123-4567 Relationship: Mother Contact Notified? Yes____ No_____ Date/Time: 01/01/12 - 5:00 p.m. EST* NOTIFY SECURITY after medical treatment has been provided! Indicate below which College Security Office was contacted to report the incident, whom you spoke to, and date/time of reporting. Contact your campus Security Office during normal work hours. Contact the Lake Worth Security Office (#01-561-868-3600) at all other times (24/7) or if contact cannot be made with your campus Security Office. Describe all circumstances of accident/incident and all action taken: I received a telephone call from John Smith, roommate of James Jones, advising that James slipped and fell while in the shower, injuring his head. James was bleeding profusely from just above his eyebrow. The campus’ on-call physician was contacted and advised that he would call for emergency service to transport James to the local hospital for treatment. James was treated at the hospital and received three stitches to close the wound. He was released from the hospital two hours later. I contacted James’ mother to advise her of the incident and informed her James was fine. James also spoke to his mother, assuring her he was fine. I then contacted Lake Worth Security to report the incident. Name & Title of Reporter: Linda White, Faculty Leader Date: 01/01/13