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MVM Occurrence Report
Please give a detailed, fact based account of the occurrence.
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* Indicates required question
Student Name:
*
Your answer
Witness(es):
*
Your answer
Today's Date
*
MM
/
DD
/
YYYY
Occurrence Time
*
Time
:
AM
PM
Place of Occurrence:
*
Desert Willow Classroom
Juniper Classroom
Pinon Pine Classroom
Activity Room
2-4 Playground
3-6 Playground
2-4 Bathroom
3-6 Bathroom
Other:
Required
Type of occurrence:
*
Injury
Behavior
Illness
Other:
Required
Fact based details of the Occurrence:
*
Your answer
What actions were taken? (Please mark all that apply)
*
Ice Pack
TLC
Redirection
Restorative (having children speak to each other about the occurrence and rebuilding the relationship)
Called Parents (all head injuries or out of norm behaviors, call the parents)
Removed child from activity until they calmed down or gained control of themselves.
Conversation with child about what happened, behavior, or how they feel.
Other:
Required
Were parent(s) notified? If so, when?
*
Yes, with this report
Yes, with a phone call immediately after the occurrence
Yes, with a voicemail
Yes, with a text message
No, report will be placed in students' file
Other:
Required
Were office personnel made aware of this occurrence?
*
Yes
No
Please electronically sign and date
*
Your answer
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