Incident Reporting Tool

LSU Incident Reporting Tool
If this incident occurred during an AU Club Activity outside of the LSU Building then please use the AU Accident Reporting Form
Reporters Name - Who is reporting the incident?

First NameLast Name
Reporters Area of Work/Study (Please select ALL that apply)
Was this Incident a Near Miss?
Was this an Incident of Shoplifting or attempted Shoplifting?
Date & Time of Incident

DayMonthYear
Date
Hour Minutes
Incident Location
Detailed Description of Location (if required)
Incident Details (provide details of what occurred, don't include medical details in this section)
What Actions were Taken as a Result of this Incident?
Relevant Cameras
Duty Managers Involved in the Incident (include the reporter if applicable)
Other Staff Members/Contractors Involved
Relevant Images (if you believe an image would provide better context to this report)

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Did anyone require medical attention? (this includes first aid treatment or self administered first aid e.g. applying a plaster)
- Is the patient?
  
  Other
- Patient's Student ID Number
- Patient's Name
  
  First NameLast Name
- Patient's Date of Birth
  
  DayMonthYear
  Date
- Patient's Phone Number
  Please enter a valid phone number.Format: 00000 000000.
- Patient's Email
  example@example.com
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Complaint
- PRF Number
- Description of Injury & Treatment Given
  For FREC3 and above this should be in the format PC,HxPC, O/A, O/E, Tx, Plan and should include Obs and Scores where relevant
- Further Care Pathway
- Friend's Student ID Number
- Friend's Name
  
  First NameLast Name
- Ambulance Number
- Treatment Provided By
  
  Other
- Medic's Phone Number
  Please enter a valid phone number.Format: 00000 000000.
- Medic's Email
  example@example.com
- Is the patient?
  
  Other
- Patient's Student ID Number
- Patient's Name
  
  First NameLast Name
- Patient's Date of Birth
  
  DayMonthYear
  Date
- Patient's Phone Number
  Please enter a valid phone number.Format: 00000 000000.
- Patient's Email
  example@example.com
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Complaint
- PRF Number
- Description of Injury & Treatment Given
  For FREC3 and above this should be in the format PC,HxPC, O/A, O/E, Tx, Plan and should include Obs and Scores where relevant
- Further Care Pathway
- Friend's Student ID Number
- Friend's Name
  
  First NameLast Name
- Ambulance Number
- Treatment Provided By
  
  Other
- Medic's Phone Number
  Please enter a valid phone number.Format: 00000 000000.
- Medic's Email
  example@example.com
- Is the patient?
  
  Other
- Patient's Student ID Number
- Patient's Name
  
  First NameLast Name
- Patient's Date of Birth
  
  DayMonthYear
  Date
- Patient's Phone Number
  Please enter a valid phone number.Format: 00000 000000.
- Patient's Email
  example@example.com
- Patient's Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Primary Complaint
- PRF Number
- Description of Injury & Treatment Given
  For FREC3 and above this should be in the format PC,HxPC, O/A, O/E, Tx, Plan and should include Obs and Scores where relevant
- Further Care Pathway
- Friend's Student ID Number
- Friend's Name
  
  First NameLast Name
- Ambulance Number
- Treatment Provided By
  
  Other
- Medic's Phone Number
  Please enter a valid phone number.Format: 00000 000000.
- Medic's Email
  example@example.com
- Does anyone need to be disciplined as a result of this incident?
- Is this person?
  
  Other
- Is this person a member of Casual Venue Staff?
- ID Number
- Name
  
  First NameLast Name
- Does this require escalation to an executive officer?
- Email of Ban Recipient
  example@example.com
- Requested Ban End Date
  
  DayMonthYear
  Date
  Hour Minutes
- Is this person?
  
  Other
- Is this person a member of Casual Venue Staff?
- ID Number
- Name
  
  First NameLast Name
- Does this require escalation to an executive officer?
- Email of Ban Recipient
  example@example.com
- Requested Ban End Date
  
  DayMonthYear
  Date
  Hour Minutes
- Is this person?
  
  Other
- Is this person a member of Casual Venue Staff?
- ID Number
- Name
  
  First NameLast Name
- Does this require escalation to an executive officer?
- Email of Ban Recipient
  example@example.com
- Requested Ban End Date
  
  DayMonthYear
  Date
  Hour Minutes
- Is this person?
  
  Other
- Is this person a member of Casual Venue Staff?
- ID Number
- Name
  
  First NameLast Name
- Does this require escalation to an executive officer?
- Email of Ban Recipient
  example@example.com
- Requested Ban End Date
  
  DayMonthYear
  Date
  Hour Minutes
- Has anything been broken as a result of this incident?
- The item that is broken is a
- Please describe what is broken and how it is broken?
- Attach any Relevant Images
  
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- Should be Empty:

LSU Incident Reporting Tool