ELHC Incident Report Form

Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or student behavior incidents. If possible, a report should be completed within 24 hours of the event.

Person Filing Report

The Incident

Person(s) Involved

Person 1

Person 2

Person 3

Other Person(s)

Injuries

Was anyone injured? *

Witnesses

Were there witnesses to the incident? *

Police / Medical Services

Police Notified? *
Was a police report filed?
Was medical treatment provided? *
Where was medical treatment provided?

Report Submission

Please sign below.