WELLBEING CENTRE

Student Incident Report Form (Confidential)

Use this form to report student behavior incidents. If possible, a report should be completed within
24 hours of the event.
Date of Report:………………………. Class /Section………………………..

1. STUDENTS INVOLVED (Name with Mobile number of parents)

Name of Student Contact Sign

2. THE INCIDENT
Date of Incident…………….. Time:___________ ☐ AM ☐ PM Location: ……………

Describe the Incident: ………………………………………………………………………………………

…………………………………………………………………………………………………………………

3. INJURIES
Was anyone injured? ☐Yes ☐No If yes, describe the injuries: ………………………..

4. WITNESSES

Were there witnesses to the incident? ☐Yes ☐No

If yes, enter the witnesses’ names and contact info: ………………………………………….
Authority Notified?☐Yes ☐No
Was medical treatment provided? ☐Yes ☐No ☐Refused
If yes, where was medical treatment provided? ☐On site ☐Hospital☐Other:
Counselor Signature: ________________________ Date: _____________
Reporting Person Sign: ________________________

OFFICE USE ONLY

Report received by date:____________

Principal Signature: ________________________

Action Taken:…………………………………………………………………………………………………………..

Follow-up action taken:……………………………………………………………………Date: _____________

Information to the parents? ☐Yes ☐No ☐Refusal request with last chance

Warning Letter: ☐Yes ☐No

Dyal Singh Public School, Dyal Singh Colony, Karnal