Incident Report Template

*Confidential

Instructions: Please complete this form as soon as possible after the incident. Provide as much detail as possible. Submit the completed form to [Onsite Coordinator Email].

1. Personal Information

• Full Name:
• Program Name:
• Host Institution/Organization:
• Email:
• Phone Number:

2. Incident Details

• Date of Incident:
• Time of Incident:
• Location of Incident:
• Description of Incident (Provide a detailed account of what happened, including who was involved, what actions were taken, and any witnesses):
• Immediate Actions Taken (First aid, police report, contacted ABROADER, etc.):
• Were Authorities Contacted? (Police, medical personnel, host organization, etc.)
  • If yes, please provide details (Name of authority, contact information, case number if available):

3. Additional Information

• Witnesses (Name and Contact Information):
• Any Supporting Documents Attached? (Photos, medical records, receipts, police report, etc.)
  • If yes, please list:

4. Follow-up Actions Needed

• Do you require any further assistance from ABROADER?
• • If yes, please specify:

• Additional Comments:

Student Signature: ________________________
Date: _______________

For ABROADER Office Use Only:

• Received by: ________________________
• Date Received: _______________
• Follow-up Actions Taken:

ABROADER Representative Signature: ________________________
Date: _______________