Study Abroad : IUPUI

Incident Report Form

Please use this form to describe any incidents to be reported to the Office of Overseas Study.

Name of person completing this form

E-mail address of person completing this form

Time, Date, and Location of incident/accident

Name of Student(s) involved

Nature of Incident

How, when, and from whom did you hear about the incident?

Was medical attention offered to the student(s)? Yes No

Please explain If no, why not; if yes, what happened

Did the student accept the offer to seek medical attention? Yes No

Please explain f no, why not; if yes, where was the student taken (Name/Address of hospital and attending physician)? What was the result?

Was the student offered assistance or encouraged to report the incident to local or international authorities? Yes No

If no, why not?

Did the student accept the offer to contact authorities? Yes No

Please explain If no, why not; if yes, what office was contacted (Name/Address of police station or consulate)? What was the result?