Incident Report Form

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This form should be use to report any incidents, injuries, ailments, or argument that occur.  Please provide detailed description and write legibly. 

A copy should stay in the book and incident should be reported to administration.

LOCATION: _________________________________________________ DATE: _____________________    

CHILD’S NAME: _________________________________________________ 

Description of injury, illness, allergies, ailments or argument: 

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________

 

Note other students or staff present and/or involved, if applicable. 

_____________________________________________________________________________________

 

Who notified the Parents/guardians? ____________________________________________________

Date and time of notification: ___________________________________________________________

How was parents/guardians notified?:____________________________________________________

Who notified administration? : __________________________________________________________

Date and time of administration notification: ______________________________________________ Was a copy of the report sent to the administration?     To whom?       When?      How? : _____________________________________________________________________________________

 

 

Printed name of person competing this form: ____________________________________________ Signature: _______________________                                 Whit copy to: ______________________