Incident Report • CampusOptics

Please complete this form within 24 hours of any incident involving injury to or event affecting the health and/or safety of a youth participant.

Reporter Info

Email* Required

Phone Number* Required

First Name* Required

Last Name* Required

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

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Participant name* Required

Parent/Guardian's name* Required

Parent's phone number

Program Event Name* Required

Program Director/Manager's Name* Required

Date of Incident* Required

Description of incident | injury | illness* Required

Name(s) of witnesses and phone numbers

Name of hospital or urgent care facility

Individual transported to hospital or urgent care facility?* Required

Additional action needed? If yes, explain actions taken* Required

Add files to upload as supporting documentation along with your incident report.