Incident Report

Reporting problems that arise in Center for Engaged Learning, Teaching, & Scholarship

This report may be completed by students (undergraduate and graduate), faculty, and/or community partners. For purposes of this report, an "incident" is defined as any experience you had on site, in transit to/from a site, or with a Loyola student that you feel put you, your fellow students/volunteers/staff persons, and/or your clients at risk. Your completion of this report will begin a dialogue between you, the CELTS staff, and (if necessary and appropriate) representatives of your organization aimed at managing the risk associated with your service there. Please fill out as many of the fields below as possible.

Note: If this is an emergency, please dial 911 immediately. If you are a Loyola student and in need of non-emergency medical or psychological support, please contact the University Wellness Center at (773) 508-2530.

Incident Report

Fields marked "(required)" must be completed.

Your contact information

Your name (required)

Your e-mail (required)

A phone number where we can reach you (required)

Name of the agency where you work or are serving

In what way were you engaged in serving the community?

As a student in a service-learning class
As an intern or practicum student
As a student employee through the community-based Federal Work-Study program
As a community supervisor of one or more Loyola students

Agency supervisor and course information

If you are a student, the name of your supervisor at the agency

If you are a student, the e-mail of your agency supervisor

If you are a student, the phone number of your agency supervisor

If you (or the student[s] involved) were serving in connection with a course, the course's name

For example, UNIV 290.

The course instructor's name

The incident

The date and approximate time of the incident

The location of the incident

Please describe the incident carefully (required)

Use the following questions to help you:

What were you doing when the incident occurred?
What happened? (Please respond with as many details as possible)
Who was involved in the incident?
How did you react or respond to the incident?
If applicable, how did other people respond to the incident?
What, if any, follow-up steps have you already taken to document or respond to this incident?

How should we attempt to reach you?

A member of the CEL staff will contact you as soon as possible to learn more about this incident.

Phone
E-mail
Other

If you selected Other, how should we reach you?

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Incident Report

Reporting problems that arise in Center for Engaged Learning, Teaching, & Scholarship

Incident Report