Incident Report (Non-Employee Related)
For life threatening emergencies, call 911. In all situations, please contact your Quality Assurance Coach immediately. If he/she is unavailable, contact your Regional Leader.
For incident report form/QAC/RL directory changes, have HR/RL contact receptionist@thinktogether.org.
Type of Incident *
DO NOT complete this form if the injured is an employee. For employee injuries, complete the orange Employee Injury Packet and consult your supervisor for further assistance.
Site Information
Your Region: *
Your School District: *
Your Site Name: *
Type of Program *
Where did this incident occur? *
Required
Reporting Information
Report prepared by *
FIRST NAME
Your answer
Report prepared by *
LAST NAME
Your answer
Job Title: *
Information About the Incident
Date and Time of Incident: *
MM
/
DD
/
YYYY
Time
:
Who was involved in this incident? *
Required
**If more than 2 individuals are involved, please enter full names and grade levels (if applicable) in the comment sections below.**
1. FIRST Legal Name of person involved *
Your answer
1. LAST Legal Name of person involved *
Your answer
1. Grade Level of Student Involved
If student was involved
2. FIRST Legal Name of person involved
Your answer
2. LAST Legal Name of person involved
Your answer
2. Grade Level of Student Involved
Type of Incident/Cause of Injury: *
Please check all that apply
Required
Employee/Staff Person(s) Present: *
Note: first & last names, positions
Your answer
Non-Employee Witnesses/Sources of this Incident:
Note: First and Last Names, positions and/or grade level(s)
Your answer
Where did the incident occur? *
Summarize all damages, if any.
Your answer
What occurred? *
Your answer
The following actions were taken: *
Please check all that apply
Required
What other action(s) did you take? *
List the actions in chronological order
Your answer
Is there any additional information you want to report?
Your answer
Action Items Remaining:
List any steps you still need to take
Your answer
Review Information!
Please ensure that all information entered is accurate before clicking the "Submit" button.
Have you reviewed all information entered is accurate? *
This is a legal document and accurate information is of the utmost importance
Submit
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