Incident Report – Burrell College of Osteopathic Medicine Forms

Part I – INFORMATION

Name of the person completing this form:*

First Last

Email Address:*

Enter Email Confirm Email

Phone:*

I am (a):*

Please describe:*

Date of Incident:*

Time of Incident:*

:

Location:

RAC Location:

Did this illness/accident take place while at work?

Yes
No

NM Notice of Accident or Occupational Disease Form

Please download the Notice of Accident or Occupational Disease Form, fill out the form, and uploaded the completed form here:

Accepted file types: pdf, Max. file size: 8 MB.

FL Notice of Accident or Occupational Disease Form

Please download the Notice of Accident or Occupational Disease Form, fill out the form, and uploaded the completed form here:

Accepted file types: pdf, Max. file size: 8 MB.

Location of Incident:*

Involved Parties:*

Part II – NATURE OF INCIDENT

Check all that apply

Nature of Incident:

Drug/Alcohol Deatils:*

Distribution
Possession
Use

Medical Issue Details:*

Employee
Student

Medical Issue Details:*

Accident Details:*

Student
Employee
Visitor

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COVID-19 Details:*

COVID-19 Positive
Exposure (15 or more minutes, less than 6ft)
Symptoms

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Date of most recent COVID-19 Positive test:*

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Please upload a copy of your COVID-19 positive test result:

Accepted file types: jpg, png, pdf, doc, docx, , Max. file size: 8 MB.

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Date you started quarantining:*

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COVID-19 Positive Details:*

Symptomatic
Asymptomatic

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Date symptoms began:*

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Date of COVID-19 exposure:*

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COVID-19 Exposed Details:*

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Please list the name of Burrell students, faculty, and staff you have been in close contact with (6ft or less and greater than 15 minutes) that occurred on campus starting 2 days prior to you becoming symptomatic. Please list the date you were in close contact with each individual on-campus. It is your responsibility to contact individuals you were in close contact with off-campus.*

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Do you have a book/anatomical models checked out from the Burrell Library?

Yes
No

Assault Details:*

Against Employee
Against Student

Burglary Details:*

Actual
Attempted

Robbery Details:*

Actual
Attempted

Theft Details:*

Private Property
School Property

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Sex Offense Details:*

Harassment

Harassment (Non-Title IX) Details:*

Employee
Student

Harassment (Non-Title IX) Details:*

Trespassing Details:*

Non-Student
Dismissed Students

Vandalism Details:*

Private Property
School Property

Equip/Malfunction Details:*

Damaged Materials / Equipment:*

Fire Details:*

Accidental
Arson

Weapons/Firearm Details:*

Other Details:*

Part III – DESCRIPTION OF INCIDENT

Attach statements and/or timeline if applicable. Please describe the incident in detail, and include relevant dates and times:

Description of Incident:*

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Files:

Please attached any relevant files.

Drop files here or

Accepted file types: jpg, png, pdf, doc, docx, , Max. file size: 8 MB.

Part IV – SIGNATURES

By signing below, I understand that information contained in the incident report will be held confidential to the extent possible. Information on this report may be shared with appropriate Burrell College of Osteopathic Medicine officials in order to conduct a thorough investigation, if necessary. I hereby declare that the information on this form is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation of information may result in disciplinary action.

Signature of Person Completing Form:*

Name of Person Completing Form:*

First Last

Date:*

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For Office Use Only:

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Additional Notes:

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Date:

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Signature: