Elementary Panther Safety Alert Form
**PLEASE NOTE: THIS FORM SHOULD NOT BE USED FOR WORKER'S COMP. IF YOU NEED TO FILE A CLAIM FOR WORKER'S COMP, PLEASE NOTIFY THE SCHOOL NURSE.**

Please fill out this form if you have an incident to report that occurred on the elementary school campus or with an elementary school child. If you need assistance, please contact the campus principals or counselors at (409) 267-3600. Your response will be sent via email to the elementary school administrators. Please give 1 business day for response.

I am a *
Type of incident: *
Required
Who is/was involved?
Your answer
What happened? *
Your answer
What day did it happen? *
MM
/
DD
/
YYYY
What time did it happen? *
Time
:
Where did the incident happen? *
Required
Why did this happen? What could have caused it? *
Your answer
List witnesses to what happened.
Your answer
Submit
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