Accident Report Form | Department of Dance

All accidents should be reported. Please notify the Department of Dance at 614-292-7977 for immediate assistance. Complete the form below for submission to the Academic Program Coordinator as soon as possible following the accident.

This form is for documentation purposes only and is not shared outside the Department of Dance. Submission of this form is not intended for evaluation or medical diagnosis. Students are encouraged to consult with their medical provider.

Contact Information

Name of Injured Student or Guest

Email

College

Major Program

Status

Accident Information

Date of Injury

Time of Injury

Name of Instructor or Guardian

The Accident Occured

In class

Outside class

Location

Classroom

Nature of Accident

Please be as specific as possible.

Care/Assistance

Describe the care/assistance given immediately following the accident (e.g. ice applied, wrapped, assisted to stand; called: Department [614 292-7977], emergency contact, 911, etc.)