Non-Employee Incident Reporting Form

NON-EMPLOYEE INCIDENT REPORTING FORM (Use for Students and Visitors)

Notify your Principal’s Office immediately (within 24 hours) for all incidents resulting in personal injury.
Personal Information
Name of Injured Party

First NameLast Name
Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Student's Grade
Student's Age
Visitor's Purpose

Incident Information
Date of Incident

MonthDayYear
Date
School Name
Time of Incident

Hour Minutes

AM/PM Option
Date Reported

MonthDayYear
Date
Description of Incident. Please print. (How did it happen? What was the injured person doing? What, if any, tool, machine orequipment was involved? Who was responsible for the area? Any witnesses? Use back side if necessary.
Witness Name, City, State:
Witness Name, City, State:
Witness Name, City, State:
Witness Name, City, State:

Report Completion
Report Completed By

First NameLast Name
Title
Reporting Person's Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reporting Person's Signature:
Date

MonthDayYear
Date
Should be Empty:

NON-EMPLOYEE INCIDENT REPORTING FORM (Use for Students and Visitors)