Incident/Accident Report Form

The following form is intended for anyone who has sustained bodily harm as the result of an accident or incident on the Southwest Tech campus. Please note that all information supplied will be confidential.

Fields marked with an asterisk * are required.

Contact Information

The information below pertains to the student requesting or need of support from the Office of Disability Services.

* First Name:

* Last Name:

* Address:

* City:

* ZIP:

* Phone Number:

* Email Address:

Incident Information

* Location of Incident:

* Date of Incident:

* Time of Incident:

* Relationship to Southwest Tech

You Must Choose a Relationship to Southwest Tech.

* Part(s) of body affected

* Have you injured this body part before?

You Must Choose Yes or No.

Yes
No

* Nature of Incident: Check all that Apply

You Must Choose the Nature of the Incident.

Aggressive/Threatening Behavior

Blood or Body Exposure

Building Damage

Illness

Injury

Near Miss Incident

Theft

Other

* If other, please explain.

* How did the incident occur and what activity were you engaged in at the time of the incident?

* What do you believe caused this incident?

* What recommendations would you make to prevent this incident from happening or reoccurring?

* Do you plan to seek medical attention?

You Must Choose Yes or No.

Yes
No

Signature

* Signature of Injured Party:

Report a Concern

Sometimes something just doesn't seem right, or a person just needs some assistance so a problem doesn't escalate. Bringing a concern up to those who may be able to assist the situation is the right thing to do.

Contact

Brian Kitelinger

Safety Coordinator
608.822.2376
Email Brian

Dan Imhoff

Executive Director of Facilities, Safety & Security/Title IX Director of Students
608.822.2401
Email Dan