HOW TO COMPLETE THIS FORM
 
Please complete all relevant information below and submit the completed form within 24 hours of the incident. You might not need to, or be able to, complete all sections. Please provide as much detail as possible, and that is reasonably available to you at this time. You can follow up to add or revise information as needed. 
 
Examples of incidents that should be reported include:
  • Behavioral issues and/or disruptions to individual/group dynamics
  • Damage to program facilities
  • Lost or stolen property
  • Alcohol/ Drug abuse (e.g., impacts participation in social or academic activities)
  • Accident with or without injury (e.g., bicycle or car) 
  • Harassment (e.g., aggressive pressure or intimidation)
  • Phycological issues (e.g., sudden onset of phycological condition) 
  • Minor injury when student is admitted to the Hospital (e.g., broken wrist) 
  • Theft that involves assault or break in (e.g., muggings, homestay break in) 
  • Political /Civil unrest (e.g., significant involvement of local authorities)
  • Physical Assault 
  • Allegations of Sexual Assault (see VPUL Emergency Manual) 
  • Possible Need for Medical Evacuation
  • Removing A Student from Program (willing or unwilling) 
  • Violent Protests or Riots, bomb threats, significant political unrest that disrupts the program or student safety.
  • Natural Disasters that disrupt program and threaten student safety.
  • Public Health risks/infectious disease outbreaks
  • Natural Disaster, Public health risk that is an immediate risk to students. 
  • Life Threatening Medical Emergency 
  • Kidnapping 
  • Arrest or pending arrest
  • Confirmed Missing student. 
  • Political environment that has become unsafe for students or poses immediate risk. 
  • Serious threats of Terrorism or war 
  • Serious Injury or Student Death
  • Weapons
Immediately contact the Vice Provost for Student Engagement, the VPSE Chief of Staff, and your VPSE Supervisor upon submitting this form.

Please forward any questions, comments, or concerns related to this form itself to Dann Truitt at dannt@upenn.edu