Incident Report - Host Company

ICLS Host Company Incident Report Form

Please use this form to provide ICLS with additional details regarding the recently reported incident.
Please answer all questions truthfully, and provide as much detail as possible. The information provided in this form is for the use of ICLS, and remains confidential. If the nature of the report is a serious or life-threatening matter, ICLS reserves the right to notify the proper authorities including, but not limited to the U.S. Department of State and local police.
J-1 Participant Full Name*

PrefixFirst NameMiddle NameLast Name
Program Start Date*

MonthDayYear
Date
Program End Date*

MonthDayYear
Date
U.S. Phone Number*
Host Organization Name*
Host Organization Location*

Street Address

Street Address Line 2

CityState

Zip Code
Name of Host Supervisor*

PrefixFirst NameLast Name
Host Supervisor Phone Number*
Host Supervisor Email Address
example@example.com
Date of Incident Occurance

MonthDayYear
Date

ICLS Host Company Incident Report Form