Medical Team Incident Form
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
What Campus Did the Incident Occur On?
*
Please Select
Ormond
Palm Coast
New Smyrna Beach
Panama City
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Details (what happened, nature of injury/condition, etc)
*
Treatment Given (first aid/treatment provided on site)
*
Was EMS called?
*
Yes
No
Did the ill or injured person refuse medical treatment?
*
Yes
No
Was the ill or injured person transported to hospital?
*
Yes
No
If minor, name of parent & time parent was contacted?
*
Type "n/a" if not a minor
Any additional notes?
Report Completed By
*
First Name
Last Name
Ill or Injured person Signature
Ill or Injured person/guardian signature
Submit
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