Incident Report

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Reports
Incident Report

File An Incident Report

File this report if there has been a medical or behavioral incident with an exchange student, or if you’re the student and need to get an incident on record.

If you are a Rotarian, please file the Rotary International Incident report form

Use the form below to file an incident report. In the case of an immediate emergency, please phone 911. You may also reach the Department of State (DOS) Emergency Hotline by phoning 1-866-283-9090 or by e-mailing to [email protected].

Name of Student*
First Last
Date of Situation*
Month
Day
Year
Were the local authorities contacted?*
- Yes
- No
List the responding officials:
List the agencies that received a report on the incident:
Summarize the facts:*
Report any injuries:
List any witnesses:
Describe any safety measures taken:
Describe any media coverage:
How do you know the student?*
- I am the student
- I am hosting a student
- I am a teacher or school official
- I am a Rotarian
- I am in a position of authority
- I am a friend or acquaintance of the student
- I am related to the student
- I do not know the student
Your Name*
First Last
Your Email*
Name
This field is for validation purposes and should be left unchanged.

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