Incident Report

Name of Program

Date of Incident

Location of Incident (Country, City, Place)

Was the incident on free time or program time?

YesNo

If an other incident please specify:

Level of Incident (Indicate your estimate):

Please note if you have a level 3 or 4 incident, you will first need to contact the Purdue Study Abroad Office 765-494-2383 or Purdue Police after working hours 765-494-8221 and then follow up with the incident report.

Incident Level

Level 1(Report not required): Incidents handled on-site by the individuals involved (faculty, student, local staff, others). Minor incidents involving illness, failure to attend classes, minor arguments between students, minor lost or stolen property, alcohol misuse.Level 2: Repeated or notable incidents of any Level 1, vehicle accident with significant damage (student does not appear to be injured), significant lost or stolen property (camera, passport, etc.), recurring abuse of alcohol, withdrawn or depressed student.Level 3: Level 2 issues that become chronic, any incidents involving overnight stays or significant treatment in hospitals or emergency medical response; incidents involving local police or other civil authorities, threats of violence, any type of assault or allegations of harassment.Level 4: Crisis situations involving the immediate well-being of students, faculty and staff, or significant University resources. Severe depression or behavior issue that gives reasonable cause to believe that the presence of the student constitutes danger to self or others, accident resulting in severe injuries.

Please describe the incident. Be as specific as possible, including all details and how you became aware of the incident.

Action(s) taken, including individuals contacted (police, ambulance, U.S. Consulate, family member, other program participants, etc.)

Requested follow up. Specific actions you would like the Study Abroad Office or Dean of Students to take.

Report By

Please be aware that this is a FERPA protected educational record. Those with a legitimate educations interest may have access to this form. When necessary, this may include professionals in the Dean of Students Office, Purdue Student Health Center and Purdue University Counseling Services, among others.

Name of Person Submitting Report

Preferred Method of Contact (i.e. phone, email, face to face)