EMERGENCY INCIDENT REPORTING FORM
Student and program names will be kept confidential. Once completed, please fax immediately to:
Domestic Travel: Coordinator of Special Sessions, Office of Extended Education – 1 (315) 267 3088
International Travel: Director, International Education & Programs – 1 (315) 267 4890
Today’s Date: Click here to enter a date.
Student Name: Click here to enter text.
Student ID#: Click here to enter text.
Date of Incident: Click here to enter a date.
Time of Incident: Click here to enter text.
Location of Incident: Click here to enter text.
SUNY Potsdam Staff/Faculty Completing Report and Contact Information:
Click here to enter text.
Program Name: Click here to enter text.
Others Involved: Click here to enter text.
Please check the appropriate box to indicate the nature of the incident:
Alcohol/Drugs
Theft
Assault of Student
Injury/Illness
Arrest of Student
Other, please specify Click here to enter text.
Please provide a thorough description of the incident. Be as specific as possible, including all details.
Click here to enter text.