Report • CampusOptics

The form is for reporting any noteworthy illness, medical issue, or accident/injury affecting a minor’s health/safety. The Program Director must document and submit it promptly. Complete all relevant sections and maintain a copy for your internal records. Please contact Reggie Miller at Protectionofminors@baylor.edu if you have any question or need assistance with submitting the form.

Reporter Info

Email Address* Required

Phone Number* Required

First Name* Required

Last Name* Required

Location

Campus, Building, or Outdoor Area* Required

Additional Location Details

Exact Location

Loading…

Program Information

Program Name

Program Director

Phone Number

Incident

If other, please describe

Date of Incident

Time of Incident

Description of Incident

Was incident reported to law enforcement

Injury/Illness

Describe the injury/illness

Did Police/Fire/EMS respond

If yes, what services were provided

Parent/Legal Guardian

Were parent(s) or legal guardians notified

Witness Information

First Name

Last Name

Phone

E-Mail

Affiliation to Baylor

Faculty

staff

student

external

Department of Family and Protective Services

Was Department of Family and Protective Services contacted

If yes, what day were they contacted

Add Supporting Documents

Add files to upload as supporting documentation along with your incident.