Incident Report
Form completed by
*
First Name
Last Name
Was a student involved or Injured?
*
Yes
No
Student Name
First Name
Last Name
Date of Incident:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Date of Report:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Report:
Hour Minutes
AM
PM
AM/PM Option
Incident type:
e.g., slip and fall, hit with an object, etc...
Location:
Location where the incident occurred.
Incident description:
Provide a clear and concise description of the incident
Parties involved:
List the names and roles of all individuals involved or present during the incident
Witnesses:
List the names and contact information of any witnesses to the incident
Emergency Services:
Specify if emergency services were called and provide any relevant details
Mitigation Measures:
Outline any steps taken to prevent further damage or harm
Injuries or losses:
Detail any injuries sustained or losses incurred as a result of the incident
Property damage:
Specify any damage caused to property or equipment
Incident Investigation:
Describe any investigation conducted to gather the facts
Findings:
Summarize the key findings of the investigation
Recommendations
Provide and recommendations or suggestions to prevent similar incidents in the future
Additional Information:
Include any additional relevant information that is important to the incident report
Attachments
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