Incident Report Form

Name of person reporting the incident *

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Type of incident *

School Location *

Day *

Group *

Student Involved (initials only) *

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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

Date

Time

Location at School

Please describe the incident

Please describe the injuries if applicable

Actions taken

Check all that apply

Please describe actions taken in detail

Report prepared by *

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