Preschool Student Incident Report
Reporting Teacher ESC Email
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Student Name:
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Date of Incident:
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Time of Incident:
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Place of Incident:
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Supervised By:
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Explain How Incident Occurred:
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List any visible injuries and/or first aid procedures:
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What time were parent(s)/guardian(s) notified?
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Parent(s)/Guardian(s) response
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List any other adult/student witnesses:
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By typing my name below, I certify that the information submitted on this form is true, correct, and complete.
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Other Comments:
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