Incident Report Form
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: ______________________