OFFICE OF STUDENT SERVICES

STUDENT DISCIPLINE & SECURITY UNIT

G/F, Rm. 5111
City of Dasmariñas, Cavite, P hilippines
Trunk Lines: (63) (46) 481-8000 (63) (2) 988-3100
Local: 1520 (Student Discipline & Security Unit)
DLSHSI URL: www.dlshsi.edu.ph

INCIDENT REPORT FORM

Use this form to report accidents, injuries, medical situations, or student behavior incidents. (Incidents involving a Student, Faculty, Employee and
Staff incident should be reported directly to the Office of Student Services.) If possible, the report should be completed within 48 hours of the
event. Submit completed forms to the Student Discipline & Security Unit under the Office of Student Services.

INFORMATION ABOUT PERSON INVOLVED IN THE INCIDENT

Name : __________________________________
College/Department : ___________________ Student Faculty Employee/Staff
Contact Numbers : ___________________ Email Address : ___________________

INFORMATION ABOUT THE INCIDENT

Date of Incident: Time of Incident: Location of Incident:

Description of Incident (what happened, how it happened, factors leading to the event, etc.) Be as specific as possible (atta che d
additional sheets if necessary)

Were there any witnesses to the incident? Yes or No

If yes, attach separate sheet with names, addresses, and phone numbers.

INFORMATION ABOUT THE INFORMANT

Name : __________________________________
College/Department : ___________________ Student Faculty Employee/Staff
Contact Number : ___________________ Email Address : ___________________

ACTION TAKEN (Please Don’t mark this portion for Persons in authority use only.)

Report Received By:_____________________________ Date:___________________

College/Department : ___________________________ Contact Numbers: ___________________

REMARKS:
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