OFFICE OF
International Education
INCIDENT REPORT FORM FOR OVERSEAS EMERGENCIES
Student Affected:
Program:
1) Description of incident, including whether hospitalization and/or medical services were needed and local police
response.
2) HTH Worldwide Needed?
Yes
3) HTH Contacted by:
No
Student
4) Hospitalization?
Yes
If yes, date and time called:
Parent
Marquette
No
5) Name and location of hospital:
6) Referred to hospital by:
7) Medical services needed:
8) Status of medical care and condition:
9) Local police contacted?
Yes
10) Local police contacted by:
11) Police report filed?
No
Student
Yes
If yes, date and time called:
Parent
Marquette
No
12) Contacts made: Please list persons MU has contacted and their relationship with the student.
Name
Phone numbers
Date contacted
Documented by:
Date: