Occupational Therapy Program Student Incident/injury Form

Please submit the following information to report a student incident or injury during a class, lab or school activity.

All fields marked with asterisk (*) are required.

required date field
required text field
required text field
date field
required date/time field
Date and Time of Incident:*
at
required text field
required textarea field
required textarea field
required textarea field
required textarea field
checkbox field
Was student exposed to infectious fluids/materials:
required checkbox field
Was medical evaluation and treatment pursued by student:*
date field
textarea field
textarea field