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 Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Name* Required

Additional Location Details

Exact Location

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Participant name

Parent/Guardian's name

Parent's phone number

Program Event Name

Program Director/Manager's Name

Date of Incident

Description of incident | injury | illness

Name(s) of witnesses and phone numbers

Name of hospital or urgent care facility

Individual transported to hospital or urgent care facility?

Additional action needed? If yes, explain actions taken

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