ࡱ> O &{bjbjUU 07׎e7׎e H H =y-1P\6 !,,,,,,,$g03v,Q>"\\>">",3-""">" ,">",""H+, ;:>H" +,I-0y-,3R":3,,3,$>">"">">">">">",,">">">"y->">">">"3>">">">">">">">">"H S:  FORM 5 Incident/Accident Report Take a copy of this form on your trip and use in the event of a medical emergency, accident, fight/assault or other unusual event. Organization  FORMTEXT       Activity  FORMTEXT       Date  FORMTEXT       Time  FORMTEXT       Place  FORMTEXT       People Involved: NAMEPHONEID# FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Continue on back if more space is needed Description of Incident:  FORMTEXT       Action Taken:  FORMTEXT        Who was notified? FORMCHECKBOX UPD FORMCHECKBOX City PD FORMCHECKBOX Ambulance FORMCHECKBOX Advisor FORMCHECKBOX Student Activities FORMCHECKBOX VP for Student Affairs FORMCHECKBOX Dean of Students Witnesses:NAMEPHONEADDRESS FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       Submitted by  FORMTEXT       Phone  FORMTEXT       Signature Date  FORMTEXT       Emergency procedures (abbreviated, see RSO Handbook for full text) A. Minor emergency: Handle on site and file an Incident/Accident Report with the Dean of Students upon arrival to campus. B. 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Based on the situation (state of the victim, location of accident, etc.), determine who will contact the individual listed as the emergency contact or the victim. Initiate contact. In the event of a death or serious bodily harm, refer to section C (below). Determine with the police who will contact the organization's advisor. Initiate contact. (The Assistant Director of Student Activities will fulfill the duties of the advisor in his/her absence.). File an Incident/Accident Report upon arrival to campus. C. In the event of a death: Handle on site (call 911, etc) and contact the University Police with details of the incident. The University Police will contact a university official (i.e. Vice President of Student Affairs, the Dean of Students, Provost, or President). The university official will notify the family of the victim. Do not talk to the media about the event. Refer all questions to the university Public Affairs Office. File an Incident/Accident Report with the Dean of Students upon return to campus. With few exceptions, you have the right to request, receive, review and correct information about yourself collected using this form. 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