High School/Activities School Incident Report
Email address *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Building *
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Specific Location *
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Name of Injured/Affected Person *
Your answer
Gender of Injured/Affected Person *
Grade
Phone Number
Your answer
Email Address
Your answer
Describe the Incident/Accident *
Your answer
Describe Loss/Injury *
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Weather Conditions (if applicable)
Your answer
Describe Medical Treatment/First Aid
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Name of Staff in Charge of Area/Classroom *
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Witness(es) Name
Your answer
Witness(es) Phone Number
Your answer
Witness Description of Incident Accident
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Persons/Entities Contacted
Your answer
Suggested Corrective Action
Your answer
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