NSFP Incident Report This form is to be used in case of any incidents that occur during NSFP events. Your Name* First Last Your Email* Enter Email Confirm Email Date of Incident* Date Format: YYYY slash MM slash DD Time of Incident* HH : MM AM PM Date of Report* Date Format: YYYY slash MM slash DD Incident Type* Injury/Illness - Did a participant experience an injury or illness during their experience with NSFP? (i.e. a participant sprains their ankle; a family member is throwing up outside of the Union Auditorium) Property - Was their damage that resulted to University owned property during an NSFP program? (i.e. a car accident in a University vehicle) Security - At any point during the program, was the security of our participants, staff or the facilities that we use in question? (i.e. a suspicious individual is roaming around the program; there is a door that has had it's lock tampered with) Unsafe Condition - Is their an area of the program that is currently unsafe for participants, staff, etc? (i.e. a large puddle outside of a bathroom) Near Miss - Were you involved with a situation that could have resulted in one of the above incident types, but ultimately did not? (i.e. something falls in front of a participant and doesn't injury them, but could have had they been a few steps further along) Other Other Description*Overview of IncidentDid this incident occur on the UTK campus or off?*On-CampusOff-CampusOn-Campus Location*Include building name and room number. If this happened outside of a building, please be as descriptive as possible with the location.Off-Campus Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Description of Occurrence*Include any information about the incidents. Keep all comments factual.Who has this been reported to?*UTPDLocal PoliceThis has not been reported to anyone yetWere there any emergency personnel present?* Medical/EMT UTPD Local Police Other None Please list the other emergency personnel agencies present*Parties InvolvedPlease use the fields below to provide details about the individuals involved. Please complete as much of the information below as possible. You will have the opportunity to enter up to five names. How many people were involved?*12345More than 5Name 1* First Last Address 1 Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email 1* Phone 1*Relationship to University 1*New StudentCurrent StudentFamily Member/GuestStaff MemberOutside VendorName 2* First Last Address 2 Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email 2* Phone 2*Relationship to University 2*New StudentCurrent StudentFamily Member/GuestStaff MemberOutside VendorName 3* First Last Address 3 Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email 3* Phone 3*Relationship to University 3*New StudentCurrent StudentFamily Member/GuestStaff MemberOutside VendorName 4* First Last Address 4 Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email 4* Phone 4*Relationship to University 4*New StudentCurrent StudentFamily Member/GuestStaff MemberOutside VendorName 5* First Last Address 5 Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Email 5* Phone 5*Relationship to University 5*New StudentCurrent StudentFamily Member/GuestStaff MemberOutside VendorAdditional Parties*Please list the names, emails, phone numbers, and relationships to the University of any additional parties.Did any of the parties involved require medical treatment?*YesNoUnsurePlease describe who required medical attention and the medical action taken*Was anyone transported for medical care?*YesNoWhere were they transported?*Who accompanied them to receive medical care?*If they were transported alone, please type N/A.Property DamagePlease use the fields below to provide details about the property damage. Please complete as much of the information below as possible.Description of Damage*Were any witnesses present?*YesNoUnsureWitness 1 Name* First Last Witness 1 Email* Witness 1 Phone*Witness 2 Name First Last Witness 2 Email Witness 2 PhoneWitness 3 Name First Last Witness 3 Email Witness 3 Phone