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Forms - Safety Incident Form (for faculty and students)

Please complete this form as soon as possible after the incident has happened and press the "submit" button below. Once submitted, the form will automatically be sent to the Off-Campus Programs Office at Calvin. This information will be used to follow-up to make sure the situation has been addressed as well as to keep a record of the types of incidents/illnesses taking place on Calvin's off-campus study programs. Thank you for your prompt and comprehensive reporting of the incident.

Personal Information




Incident Description

Crime

Property Loss?  
Threat of Violence?  
Personal Injury?  
Instructor Informed?  
Parents Informed?  
Police Report Filed?  
     If yes, Police Report #

  

Illness

Hospitalization/Medical Consultation?  
Payment for Services?
Instructor Informed?  
Parents Informed?  

  

  

Please click on the "Submit" button to return send your form to the Off-Campus Programs Office.