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Wilfrid Laurier University Leaf
August 27, 2014
 
 
Canadian Excellence

Post-Activity Incident Report



For a printable version of this form see under "forms" on the Laurier International website  


Laurier University Risk Policy for International Activities

Post-Activity Incident Report

In Accordance with the Laurier University Risk Policy for International Activities, this form is to be completed by the Principal Investigator/ Activity Leader at the end of an International Activity if an incident occurred during the activity.  The Report is to be submitted within two weeks of the conclusion of the activity to the Department Director/ Chair with which the International Activity is affiliated.  A copy is to be forwarded by the Department Director/ Chair to the Manager, Programs and Services of Laurier International, and to the appropriate Dean or VP.

 

Examples of incidents that could be reported include but are not limited to: serious illness or injury, fatal accident, vehicle accident, death, assault, hate crimes or other violent occurrences, political or civil unrest, natural or environmental disaster, visa and immigration issues, and theft.

Department  □ __________________________

 

Student Group  □ ________________________

 

Individual: □  ___________________________

Activity Coordinator (Applicant and overseer of Activity.  May or may not lead the Activity):

Name: __________________________________

 

Email:___________________________________

 

Phone:___________________________________

Purpose of International Activity:

 

□ Academic:  Undergraduate ____    Graduate ______       

 

□ Research          □ Other ญญ_______________________

Team Leader (if different from Coordinator ):

Name: ___________________________________

 

Email: ___________________________________

 

Phone: ___________________________________

Number of Participants:

 

 

Nature of International Activity:

 

 

Student Group if applicable (Course # or Team Name): ____________________________________

Location of Off-Campus Activity (please be specific: country, city, urban or remote, etc):

 

 

 

Date and Duration of Off-Campus Activity:

1. During the course of the international activity, were you required to respond to a critical incident, as defined in Section 7.5 of the Wilfrid Laurier University Risk Management Policy for International Activities?

 

Yes □     No □

If yes, please provide details about the nature of the incident, the response and final outcome:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Were the participants required to undertake training apart from international pre-departure training (eg. Safety procedures, use of equipment, specialized training) prior to taking part in the international activity?

Yes □   No □  

If yes, please specify the nature of the training.

 

 

 

 

 

 

3. Did the training address all contingencies encountered during the activity?

Yes □   No □

If no, please explain.

 

 

 

 

 

 

4. For future international activities of this nature, would you recommend any changes to the training?

Yes □  No □

If yes, please specify.

 

 

 

 

 

 

 

 

5. Additional comments:

 

 

 

 

 

 

 

Person Completing the Post-Activity Incident Report:

 

_______________________________

Name & Title

 

_______________________________

Signature

 

ญญญญญญญญญญ_______________________________

Date

 

□ Principal Investigator/ Activity Coordinator

□ Team Leader

Confirmation of receipt of Post-Activity Incident Report:

 

_____________________________

Name & Title

 

_____________________________

Signature

 

_____________________________

Date