STUDENT INCIDENT REPORT TEMPLATE

REPORTED BY:	DATE OF REPORT:
TITLE / ROLE:	INCIDENT NO.:

STUDENT INCIDENT INFORMATION
STUDENT NAME:	GRADE LEVEL:
DATE OF INCIDENT:	TIME OF INCIDENT:
LOCATION:
SPECIFIC AREA OF LOCATION:
ADDITIONAL PERSON(S) INVOLVED:
WITNESSES:
INCIDENT DESCRIPTION:
DESCRIPTION OF UNACCEPTABLE / UNSAFE BEHAVIOR OR CONDITIONS (if applicable):
RESULTING ACTION EXECUTED OR PLANNED:

EMPLOYEE NAME:	EMPLOYEE SIGNATURE:	DATE:
SUPERVISOR NAME:	SUPERVISOR SIGNATURE:	DATE:

–OPTIONAL–STUDENT NAME:	STUDENT SIGNATURE:	DATE:

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