INCIDENT REPORT FORM

Use this form to report any accident, injury, theft, violations, incident, illness, others
Submit completed form to the School Principal/Administrator.

This is documenting a/an:

Violation Accident Incident Illness Observation Others

Teacher Completing Report:__________________________________ Date:__________

Student(s)/Person(s) Involved:________________________________________________
Grade Level:______________
Date of Event:______________ Location of Event:________________________________

Time of Event:_____________ Witnesses:______________________________________

Description of Events (Describe sequence of events):

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*If more space is required, please use the back of this sheet

Action Already Taken (if any):

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Suggestion/Recommendation/Remarks:
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Signature of Teacher:_____________________________ Date:__________________