Incident Report

Please fill out this form and click submit.

Use this form to report accidents, injuries, medical situations, criminal activities, traffic incidents, or student behavior incidents. If possible, a report should be completed within 24 hours of the event.

Name of Person Completing Form

Name

*

Email

*

This address will receive a confirmation email

Phone

*

Address

*

Person #1 Involved

Name

*

Phone Number

Email

Address

Person #2 Involved

Name

Phone Number

Email

Person #3 Involved

Name

Phone Number

Email

Use this Space to List any Additional Persons

The Incident

Date of Incident

*

Time

*

Location

*

Description of Incident

*

Injuries

Was Anyone Injured?

*

Please select one option.

Yes No Option

Comments

Witnesses

Were there witnesses to the Incident?

*

Please select one option.

Yes No

Comments

Police/Medical Assistance

Was the Police Notified?

*

Please select one option.

Yes No

Was the Ambulance Called?

Please select one option.

Yes No

Was Medical Treatment Provided?

Please select one option.

Yes No Refused

Comments

Damage to Equipment/Property

Was there Damage to Equipment or Property?

*

Please select one option.

Yes No

Comments

Description

Please fill out this form and click submit.

Please Fix the Following

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