STUDENTS CRITICAL INCIDENT REPORT
Ministry of Education, Youth and Information
School and Official Info:
Data of incident: *
MM
/
DD
/
YYYY
Time of incident: *
Time
:
Name of School: *
Your answer
School Region: *
Location(Address):
Your answer
Position of person completing form: *
Your answer
Contact no: *
Your answer
Students involved in incident:
Student 1 Name: *
Your answer
Student 2 Name:
Your answer
Student 3 Name:
Your answer
Student 4 Name:
Your answer
Description, background, circumstances and relevant information leading up to the incident, and whether the incident was witnessed:
Your answer
Injury Sustained
Was any injury sustained as a result of this incident?
If yes, was medical attention sought?
Was there any property damage as a result of this incident?
Who was informed of the incident? *
Actions taken to date:
Your answer
Any follow up actions planned?
Your answer
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