Staff Behavioral Injury Incident Report

Each building should have a copy of what we call the “Staff Behavioral Injury Incident Report”. This form should be filled out each time you are involved in a physical attack by a student. In the event of an injury or assault by a student, kindly complete the hard copy, retain a copy for your records, submit one to the school office, and also complete this electronic form for submission to the WHEA. Our aim is to track these incidents diligently, and as we gather more data, we are committed to addressing the issues to ensure a safer environment for all. Thank you for your attention in this matter. 

Brian Putkonen WHEA President
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Employee Name
School
Position
Program
Date of Incident
MM
/
DD
/
YYYY
Date of Report
MM
/
DD
/
YYYY
Start Time of the Incident
Time
:
End Time of the Incident
Time
:
Did the incident result in the loss of time at work?
Clear selection
Description of the Incident (Please use student initials only in the electronic report)
Description of the injury
Was initial first aid provided?
Clear selection
Was there a report created by the nurse?
Clear selection
Nurse that was involved
Was there a referral to a District health clinic?
Clear selection
Did you accept the referral and receive medical care?
Clear selection
Witness(es) to the incident and role(s)?
Do you have a current PMT certification?
Clear selection
Does the student involved have a behavior plan?
Clear selection
Initials of the student only ( to help us match with the hard copy)
Does the incident warrant further investigation?
Clear selection
Was this matter handled to your satisfaction by the administration? Please explain if necessary.
Submit
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