Incident Report Form
Complete the following report when an incident occurs as soon as possible after the incident.
Location of Incident *
Your answer
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Name of person making report *
Your answer
Relationship to school *
Phone Number *
Your answer
Email *
Your answer
What activity was the person making the report engaged in at the time of the incident? *
Your answer
Description of the incident *
Your answer
Action taken at the time of the incident by the person making this report *
Your answer
Name(s) of any witnesses
Your answer
By writing my name in the box below, I hereby acknowledge that I truthfully answered the above questions to the best of my abilities regarding the stated incident. *
Your answer
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