A Place Where Children Blend With Nature
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: ______________________