The following form is intended for anyone who has sustained bodily harm as the result of an accident or incident on the Southwest Tech campus. Please note that all information supplied will be confidential.

Fields marked with an asterisk * are required.

Contact Information

The information below pertains to the student requesting or need of support from the Office of Disability Services.

Incident Information

* Relationship to Southwest Tech

You Must Choose a Relationship to Southwest Tech.

* Have you injured this body part before?

You Must Choose Yes or No.


* Type of Injury/Exposure: Check all that Apply

You Must Choose an Injury/Exposure

* Nature of Incident: Check all that Apply

You Must Choose the Nature of the Incident.

* Do you plan to seek medical attention?

You Must Choose Yes or No.


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