NW Islamic School
Incident Report Form
NW Islamic School prioritizes the safety and well-being of all students and staff. This form is used to document incidents that occur on school premises or during school-related activities, ensuring appropriate follow-up and resolution.
Reporting Information
Report Filed By:
Role/Position:
Date of Report:
-
Month
-
Day
Year
Date
Date of Incident:
-
Month
-
Day
Year
Date
Time of Incident:
Hour Minutes
AM
PM
AM/PM Option
Location of Incident:
Type of Incident
Type of Incident
Physical injury
Bullying or harassment
Health/medical emergency
Safety hazard
Verbal altercation
Property damage
Behavioural incident
Other
Individuals Involved
Individuals Involved
Rows
Name
Grade / Role
Student Involved
Student Involved
Staff Involved
Witness
Back
Next
Description of Incident
Please provide a detailed, factual account of what occurred:
Immediate Action Taken
First aid administered
Parent/guardian contacted
Student removed from situation
Emergency services called (911)
Other:
Details of action taken:
Follow-Up Required
Parent/guardian meeting
Counselling referral
Disciplinary action
Investigation required
No further action required
Other:
Signatures
Reporting Staff Signature:
Date:
-
Month
-
Day
Year
Date
Administrator Signature:
Date:
-
Month
-
Day
Year
Date
Parent/Guardian Signature (if applicable):
Date:
-
Month
-
Day
Year
Date
OFFICE USE ONLY
File Reference Number:
Follow-up Completed:
Yes
No
Date Closed:
-
Month
-
Day
Year
Date
Notes:
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