Incident Report Form Intern DetailsName First Last Phone Number:Email South African Address Departure Date (DD/MM/YYYY) Internship Site Did you come through a partner program or university back home?Please selectYesNoWhich one? Incident DetailsIncident Date (DD/MM/YYYY) Approximate time of incident Location of incident Who else were you with (if anyone)? Did you call the emergency VAC line?Please selectYesNoWho at VAC have you contacted? Please explain what happened below:How are you feeling about the incident?Please select123456789101= very upset, distraught 10=fine, not worriedWould you like to see a counsellor to debrief this incident?Please selectYesNoHave you contacted a parent or guardian back home?Please selectYesNoAdditional DetailsPossessions lost (if applicable) Value of goods lost (if applicable) Have you been to the police station? (if applicable)Please selectYesNoName of police station, case number, and officer assigned to your case Have you been to a clinic or hospital? (if applicable)Please selectYesNoName of clinic, doctor, and treatment plan/diagnosis
