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The supervisor should add any additional information in the form of attachments and submit to Risk Management as soon as possible.  \nCampus, Department and Program  Student Name:   Student ID \\# :   Date of Incident:   Date of Report:   Place Incident Occurred (specify facility and unit/department):   Incident Description:  Person(s) involved in the Incident:   Instructor/Preceptor or Supervisor Name:  \n\n| Describe the chain of events leading up to the incident:  \u003Cbr>______________________________________________________________________ |\n| --- |\n| Detail what equipment was being used:   Was Personal Protective Equipment required? Yes or No\u003Cbr>If yes, what was required?   Was the Personal Protective Equipment used at the time? Yes or No\u003Cbr>Initial Response Action(s), such as flushing, washing, medical care, counseling, etc.: |\n| Describe planned follow-up action(s), such as medical care, etc  \u003Cbr>Signature of Student:   Date   Student Contact Information: |\n\n________________________________________________________________________________________  \nStudent Signature:   Date:  Supervisor Signature:   Date:   Attach any Additional Comments:  \nOriginal: EHS Specialist, Risk Management Copy: Student and Supervisor  \nForm ST07 Revised 11/01/13","cbCaiq1KGM0OQlGR","https://ap.wps.com/l/cbCaiq1KGM0OQlGR","pdf",38662,"English","# Reporting Timeline and Submission Workflow\n# Incident Details and Parties Involved\n## Chain of Events and Equipment\n## PPE Requirements and Usage\n## Initial Response Actions and Planned Follow-up\n# Signatures, Dates, and Contact Information\n## Additional Comments and Copies","[{\"question\":\"When should the student complete and submit the incident report?\",\"answer\":\"The student should complete it within 24 hours or as soon as possible after the incident occurs, and submit it to the supervisor.\"},{\"question\":\"What responsibilities does the supervisor have after receiving the form?\",\"answer\":\"The supervisor adds any additional information via attachments and submits the completed materials to Risk Management as soon as possible.\"},{\"question\":\"What key details must be included in the incident report?\",\"answer\":\"The form requires incident location, a description, people involved, the chain of events, equipment used, whether PPE was required and used, initial response actions, planned follow-up actions, and student contact information with required signatures and dates.\"}]","Student Clinical Incident Report Form - Revised 11/01/13 | PDF",1789271781]