Adverse occurrence report

Date of incident: _______________ Time: ________ AM/PM


Name of injured person:


Phone Number(s):

Date of birth: ________________ Male ______ Female _______

School name: ______________________________________________

Type of injury:

Details of incident:

Injury requires physician/hospital visit? Yes ___ No _____

Name of physician/hospital:


Physician/hospital phone number:

Signature of injured party _______________________________________________

*No medical attention was desired and/or required.

Form must be forwarded to and reviewed by simulation center Director within 24 hours of incident.