WNS Incident Report Form

Incident Report
Child's Name

First NameLast Name
Staff Member Completing Form

First NameLast Name
Child's Assigned Classroom (email)
Send a copy of this report to parent?

Yes pleaseNo thanks
Primary Parent Contact Name
Primary parent's email (for a copy):
example@example.com
Secondary Parent Contact Name
Secondary parent's email (for a copy)
example@example.com
Incident Date & Time

MonthDayYear
Hour MinutesAM/PM Option
Observer #1 (if applicable)

First NameLast Name
Observer #2 (if applicable)

First NameLast Name
Observer #3 (if applicable)

First NameLast Name
Observer #4 (if applicable)

First NameLast Name
Location of Incident

101 Front Desk108 Directors Office102 Clover109 Columbines112 Shooting Stars113 Daffodils117 Buttercups118 Daisies120 Bluebells121 KitchenHallwayBathroomPreschool PlaygroundToddler PlaygroundInfant PlaygroundBeyond School BoundariesOther
Description of Incident
Possible Motivation (if applicable)

Obtain attentionAvoid a peer or adultObtain preferred itemAvoid a task or objectSensory seekingEmotional reaction to a triggerDidn't understand expectationsOther
Length of Cooldown
Consequence/Treatment

Removed from activityRedirected to another activityAttention to hurt or injured areaAttention to hurt or injured area of other child(ren) involvedOther
Parent Communication

Emailed copy of report (above)Phone callNotified in ELV messageSchedule MeetingNotify parent(s) of other child(ren) involvedOther
Plan to Prevent Recurrence of Incident (if applicable)
Should be Empty: