Part I – INFORMATIONName of the person completing this form:* First Last Email Address:* Enter Email Confirm Email Phone:*I am (a):*OMS IOMS IIOMS IIIOMS IVEmployeeOtherPlease describe:* Date of Incident:* MM slash DD slash YYYY Time of Incident:* : Hours Minutes AM PM AM/PM Location:Las Cruces (NM) CampusMelbourne (FL) CampusRAC LocationRAC Location:AlbuquerqueEastern NMEl PasoFour CornersLas CrucesSpaceCoastTucsonDid this illness/accident take place while at work? Yes No NM Notice of Accident or Occupational Disease FormPlease 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 FormPlease 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 INCIDENTCheck all that applyNature of Incident: Drugs/Alcohol Medical Issue Communicable Disease Exposure/Infectious Disease (e.g- needle stick) FERPA Violation Accident Assault Burglary Robbery Theft Harassment (Non-Title IX) Trepassing Vandalism Equip/Malfunction Fire Weapons/Firearm Damaged Materials / Equipment Other Drug/Alcohol Deatils:* Distribution Possession Use Medical Issue Details:* Employee Student Medical Issue Details:* Accident Details:* Student Employee Visitor HiddenCOVID-19 Details:* COVID-19 Positive Exposure (15 or more minutes, less than 6ft) Symptoms HiddenDate of most recent COVID-19 Positive test:* MM slash DD slash YYYY HiddenPlease upload a copy of your COVID-19 positive test result:Accepted file types: jpg, png, pdf, doc, docx, , Max. file size: 8 MB.HiddenDate you started quarantining:* MM slash DD slash YYYY HiddenCOVID-19 Positive Details:* Symptomatic Asymptomatic HiddenDate symptoms began:* MM slash DD slash YYYY HiddenDate of COVID-19 exposure:* MM slash DD slash YYYY HiddenCOVID-19 Exposed Details:*HiddenPlease 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.*HiddenDo 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 HiddenSex 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 INCIDENTAttach statements and/or timeline if applicable. Please describe the incident in detail, and include relevant dates and times:Description of Incident:*HiddenFiles:Please attached any relevant files. Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, , Max. file size: 8 MB. Part IV – SIGNATURESBy 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:* MM slash DD slash YYYY HiddenFor Office Use Only:HiddenAdditional Notes:HiddenDate: HiddenSignature: Δ