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USD 473 Incident Report Form
Please utilize this form to report student and/or staff incidents.
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Incident Report
Date of Report
*
MM
/
DD
/
YYYY
Name
*
Name of person who was involved in the incident.
Your answer
Date of Birth
*
Your answer
The Incident
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Location of Incident
*
Blue Ridge Elementary School
Chapman Elementary School
Chapman Middle School
Chapman High School
Enterprise Elementary School
Rural Center Elementary School
Other:
Describe the Incident
*
Your answer
Injuries
Was anyone injured
*
Yes
No
If yes, describe the injury and care provided
Your answer
Witnesses
Was the incident witnessed
*
Yes
No
If yes, witness name
Your answer
Additional information
Your answer
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