Request Information
877.949.3248
About Davis
Academics
Admissions
Student Life
Alumni & Friends
Contact Us
Incident Report
This form is to be completed for any accident or incident involving a student, employee or visitor.
*
Call 911 in an emergency.
*
Section 1 - Patient Information
Name
*
Address
*
Phone
*
Age
*
Gender
Male
Female
*
Employee
Student
Visitor
*
Department & Job Title
*
Reason for being on campus
*
Section 2 - Incident Report
Nature of Incident
Accident/Injury
Illness
Physical Altercation
Other
*
Date of Incident
*
Time of Incident
*
Location of Incident
*
Brief description of injury or illness
*
Briefly explain what happened: (activities occurring when injury or illness occurred, what tools, machinery or chemicals were involved, what happened to cause this injury or illness)
*
Section 3 - Action Taken
First Aid given
*
First Aid given by
*
Taken to hospital
*
Taken to hospital by
*
Sent to walk-in/physician
Instructed to rest in residence hall/at home
Continued activity (no action taken)
*
Seen by physician?
Yes
No
*
Where seen
*
Time seen
*
Name of physician
*
Witnesses (Names & Phone Numbers)
*
Name of Person Submitting Report
*
Comments
*
1 Chrisfield Ave.
Johnson City, NY 13790
877.WHYDC4U 877.949.3248
Quick Links
Home
About Davis
Academics
Admissions
Student Life
Alumni & Friends
Contact Us
Resources
My Davis
Net Price Calculator
Employment as Davis College
Bookstore
Davis Dollars
Enrollment Verification
Transcript Request
Consumer Information
© 2016 Davis College