Incident Report Form

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Name of person reporting the incident *

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Type of incident *

Student Involved *

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Student Involved #2 (if applicable) *

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Student Involved #3 (if applicable) *

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Witness

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Witness #2 (if applicable)

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Date / Time of incident

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School Location *

Location at School

Please describe the incident

Please describe the injuries if applicable

Actions taken

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Please describe actions taken in detail

Report prepared by *

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