Incident Report Form s1

Entry-Level Athletic Training Education Program

INCIDENT REPORT FORM

Date: ______

ATS Name: ______

ACI/CI Name: ______

This Incident Report Form is to be completed and submitted to the Director of Clinical Education in the event an ACI/CI asks an ATS to leave the clinical affiliate site due to non-compliance with the policies and procedures published in the Athletic Training Education Program Policy and Procedure Manual or due to non-compliance with the policies and procedures published in the Policy and Procedure Manual for the clinical affiliate site.

To be completed by the ACI/CI and submitted to the Clinical Coordinator:

The ATS was removed from the clinical education experience due to (Check all that apply):

  Tardiness

  Violation of confidentiality

  Violation of the Dress Code

  Unsafe Athletic Training Practice

  Other: ______

Comments:

In order for the ATS to return to the clinical education experience, the student must (Check all that apply):

  Demonstrate immediate compliance with the policies and procedures and return to the clinical education experience on the same day of the incident.

  Meet with the ACI/CI to review the policies and procedures and discuss compliance prior to returning to the clinical education experience.

  Meet with the Clinical Coordinator to receive permission to return to the clinical education experience.

  Meet with the Academic Program Director to receive permission to return to the clinical education experience.

I have discussed my reasons with the ATS for removing him/her from the clinical education experience. YES / NO

The ATS understands that the clinical education experience hours accumulated on the day of the incident will not be counted toward the requirements for the course in which they are enrolled, nor will the clinical education experience hours accumulated on the day of the incident be counted toward the requirements for graduation. YES / NO

______

Approved Clinical Instructor’s/Clinical Instructor’s Signature Date

______

Athletic Training Student’s Signature* Date

* Signing this form does not indicate agreement on behalf of the ATS for the reasons in which he/she was removed from the clinical education experience.

Form received on: ______

Date

______

Signature, Clinical Coordinator Date

______

Signature Academic Program Director’s Date