JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Incident Report
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Your name:
*
Your answer
Incident type
*
Choose
health issue/concern
major behavior incident
major emotional incident
injury that did NOT result in emergency services being called
injury that resulted in emergency services being called
stranger on campus
damage to property/building
other
Briefly describe the incident; what happened, how it happened, factors leading to the event, etc. Be as specific as possible.
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Around what time did this incident happen?
*
Your answer
Were any parents/guardians called or texted as a result of this incident? If so, please give details about the communication process.
*
Your answer
Location that incident occurred, please be specific:
*
Your answer
Please list the full names of any other people or persons associated with NHH who witnessed this incident; this includes students, staff, interns, parents and volunteers.
*
Your answer
Check boxes for any of the following actions that happened following the incident:
*
The police arrived on site at NHH
You have notified your immediate supervisor of this incident
You or anyone related to the incident called 911
Any other emergency vehicle arrived at NHH; this could include the Fire Department, Sheriff, Highway Patrol, FBI, Bomb Squad, Animal Control, etc.
Other people on site was made aware of the incident
none of these
Other:
Required
Are there any next steps or actions you’d like to see happen as follow-up from this incident?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Neighborhood Homework House.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
