Staff Incident/ Concern Report

Complete the entire form to the best of your ability.  If the report does not provide the complete picture – then it is probably incomplete.

Be concise but provide sufficient detail.  

Write the names of all the individuals involved in the incident including witnesses on the line reporting “Person(s) involved in the incident”.

Explain who the individuals are that are involved in the incident.  If it is another child care worker, identify that person as a child care worker; if it is a site leader, identify that person as the site leader, and so on for building staff.

Write only what you saw or heard – not your thoughts or feelings.  Do not use subjective words, extreme adjectives, or words that imply or perceive emotion (always, awkwardly, perfectly, never, very, angry, anxiously, etc).

You will be notified that the issue was addressed but you will not be informed as to what action the administrator took.  

Sign in to Google to save your progress. Learn more
Person reporting the incident *
Date report was completed *
Person(s) involved in the incident *
Date the incident occurred *
Location the incident occurred *
Description of the Incident *
Email address to contact you after concern has been addressed *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Independent School District 728. Report Abuse