Student Incident

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(UPD is available 24 hours a day/ 7 days a week) REPORT INFORMATION Faculty Member Making Report: Contact Number: Email: Responding Host Institution/ In-country Coordinator: Program Name: Date of Report: STUDENTS INVOLVED Student Name: Student ID Number: Student Name: Student ID Number: Student Name: Student ID Number: Current location/status of student(s) involved in the incident: Name of individual currently with the student(s) if not the faculty member: Relationship of this individual to the study abroad program: Contact information for this individual: CRITICAL INCIDENT BACKGROUND INFORMATION Location (include city and country): Date of Incident: Time: Individual to Contact: Nature of Incident: Injury (specify): Riot Physical Assault/Mugging Natural Disaster Accidental Death Other: Place to Contact: Death in Family Sexual Assault Hostage Suicide/Attempt Missing Student Hospitalization Stalking Drug/Alcohol Overdose Infectious Disease Mental Health Crisis Details of Incident: On a separate paper, describe what happened..

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