Calgary Quest Children's Society Incident Report
Action Taken (Please indicate one of the following):
*
High (Ambulance needed)
Medium (Medical attention recommended)
Low (Minor First Aid)
No First Aid Required
List of Staff Members Involved:
*
Rows
First and Last Name
Position
1.
2.
3.
4.
5.
Location of Incident:
*
Incident Date and Time:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Hour Minutes
AM
PM
AM/PM Option
Name of student involved:
First Name
Last Name
Student Date of Birth (if applicable):
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Student Classroom (if applicable):
Peach
Yellow
Cedar
Rainbow
Aspen
Poplar
Chinook
Horizon
Sunshine
Oak
Safari
Sage
Juniper
Parent Name:
*
First Name
Last Name
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parents/Guardians Notified:
*
Yes
No
Attempted Unsuccessfully
Emergency Contact Notified:
*
Yes
No
Attempted Unsuccessfully
Please Provide Details:
*
Describe the incident:
*
Describe what happened before the incident:
*
How long did the incident last?:
*
What follow up (if any) was done or expected:
*
Please indicate the type of transportation (if any) used:
*
None
Ambulance
Other
Name of staff member filling out this form:
*
First Name
Last Name
Signature:
*
Submit
Should be Empty: