Injury/Surgery Accommodation Reporting Form

Background Information

BACKGROUND INFORMATION SECTION TEXT

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Your full name:

Your relationship to student:

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(i.e. Self, Friend, Roommate, RA, Faculty, Staff, Parent)

Your phone number:

Your email address:

Email address must be of a valid format.

Date of Report(Required):

This field is required.

Location of incident(Required):

This field is required.

Involved Parties

Full Name

Select Gender

Select Role

ID Number

DOB (YYYY-MM-DD)

Phone number

Email address

Hall/Local Address

Questions

Please be as detailed as possible and describe the student's injury or surgery, and if you believe there is anything that might help them.

NOTE: If you submit this report anonymously, we will not be able to communicate with you to get more information so it is important that you are as detailed as possible.

Please be as detailed as possible and describe the student's injury or surgery, and if you believe there is anything that might help them.(Required) This field is required.

Please indicate if the student is an athlete.(Required)

Athlete Not an Athlete

This field is required.

Person from the AIC community with whom you believe this student has a close relationship. (i.e. Coach, Advisor, Faculty, or other Staff) This field is required.

Please indicate if the student will be having surgery related to their injury.(Required)

Student requires surgery Student does not require surgery Unknown if the student requires surgery or not

This field is required.

Supporting Documentation

Please attach any supporting documentation you feel would be helpful in assessing this report (documents, photos, etc.). ***DISCLAIMER: Only the student or family should upload photos or documentation. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Involved Parties

Questions

Supporting Documentation

Submission