EE Concern/Incident Report Form

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Please use this form to report concerns, accidents, injuries, medical situations or behavioral incidents that occur on the EE campus or in connection with EE sponsored events. If possible, the report should be completed within 24 hours of the incident.

NAME of person submitting form: *

TYPE of concern, occurrence or incident: *

Medical

Behavioral

Safety

Educational

Spiritual

Emotional

Discrimination

Harassment

Other:

DATE of occurrence/incident: *

If you are unsure, please share the date you first became aware of the situation.

NAMES of individuals involved: *

Please DESCRIBE the concern, occurrence or incident in detail: *

Names of WITNESSES: *

Please list any witnesses who may have seen the occurrence or incident when it occurred. If none, please put "none".

Please describe any known INJURIES: *

If none, please put "none".

Please describe any ACTIONS taken by EE volunteers, staff or bystanders. *

If none, please put "none".

Has EE Administration been NOTIFIED of the concern, occurrence or incident? *

Yes, immediately.

Yes, later the same day.

Yes, later on a different day.

This report is the only notification.

Other:

Comments

Please include any additional information you would like to provide regarding this incident.

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