Incident Report

Incident Report
Staff Name

First NameLast Name
Date of Incident

MonthDayYear
Date
Time of Incident

24 Hour Format Minutes
Describe Incident, People Involved & Action Taken
Witness Statement(s) (Those Who Were Around & Saw The Incident Take Place)
Staff Signature
* OFFICE USE ONLY *

Additional Action:

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Program Director Signature:__________________ Date:__________

Other Party Signature:_________________________ Date:__________
Should be Empty: