WNS Incident Report Form

Incident Report
Child's Name*

First NameLast Name
Staff Member Completing Form*

First NameLast Name
Child's Assigned Classroom (email)*
Primary Parent Contact Name*
Primary parent's email (for a copy):
example@example.com
Primary parent's email (for a copy) BLUEBELLS
Primary parent's email (for a copy) DAISIES
Primary parent's email (for a copy) BUTTERCUPS
Primary parent's email (for a copy) DAFFODILS
Primary parent's email (for a copy) SHOOTING STARS
Primary parent's email (for a copy) COLUMBINES
Secondary Parent Contact Name
Secondary parent's email (for a copy)
example@example.com
Secondary parent's email (for a copy) BLUEBELLS
Secondary parent's email (for a copy) DAISIES
Secondary parent's email (for a copy) BUTTERCUPS
Secondary parent's email (for a copy) DAFFODILS
Secondary parent's email (for a copy) SHOOTING STARS
Secondary parent's email (for a copy) COLUMBINES
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: