Student Incident Form
Please fully complete the form including codes.
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Which school does the student attend? *
Alleged Incident Date *
MM
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DD
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YYYY
Alleged Incident Time *
Time
:
Student Last name *
Student First name *
Student Home Address *
Student Home Telephone Number
Student date of birth *
MM
/
DD
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YYYY
Student Grade *
Building/Location Code:
Description of location
ALLEGED INCIDENT INFORMATION
Reported by (Last, First) *
Today's Date *
MM
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DD
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YYYY
Current Time *
Time
:
Describe how alleged incident occurred *
BOCES Activities/Class *
Person supervising student (Last, First) *
Please describe the alleged injury (include part of body) *
Name/Address/Telephone of any witnesses (please indicate if none) *
CODES
Activity *
Injury/Damage *
Part of Body *
Was first aid rendered *
If yes, by whom/date/time
Describe first aid:
Did student remain in school remainder of day/activity? *
Did student receive medical attention by a physician or hospital? *
If yes, describe medical attention. If unknown, please state.
Name/Address/Telephone # of physician or hospital
Emergency Contact Information
Was a parent present for the injury? *
Person Contacted/Relationship
Address
Telephone #
Contacted by (Last, First)
Date
MM
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DD
/
YYYY
Time
Time
:
If emergency contact was not contacted, please state reason.
ELECTRONIC SIGNATURE. (Please type your full name) *
Today's date *
MM
/
DD
/
YYYY
Title *
Email address of person completing this form *
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