Student Concerns and Incident Report Form

This form must be completed whenever a staff member becomes aware of a situation involving a VACorps intern that could impact their health, safety, wellbeing, participation, or community experience.

Use this form to document:

  • Medical incidents (e.g. clinic or doctor visits, illness, injury, chronic condition concerns)

  • Mental health concerns (e.g. withdrawal, mood shifts, emotional distress)

  • Behavioral concerns or repeated disciplinary issues (lateness, absenteeism, community disruption)

  • Interpersonal conflict or housemate complaints

  • Intern involvement in or exposure to a crime (theft, assault, break-ins, etc.)

  • Substance use, risky behavior, or safety concerns

  • Patterns of low-level concern that may indicate a larger issue

  • Any incident that may require monitoring, follow-up, or referral

(What happened? What did the intern report? What did you observe?)
(List names and roles of other staff, housemates, clinic staff, or external parties)
(E.g. escorted intern to hospital, offered check-in, notified Safety Officer, called emergency services, relocated intern)
(Past behavior, unresolved issues, ongoing concerns, patterns noticed)
(E.g. monitor closely, schedule follow-up meeting, refer for counselling, notify housing partner, debrief session)