Incident Report Form
Incident Details
Date of incident:
Type of incident:
Specific Location:
Day of the week:
Time:
Affected Person
Full Name:
Address:
Phone number:
Email:
Date of Birth
Report
Reported by:
Reported to:
Date reported
Reported to parent guardian (name)
Treatment Information
First Aid:
Yes
No
Doctor:
Yes
No
Ambulance
Yes
No
Details of Alleged Injury
Describe the injury
Description of Incident
Describe the incident:
Witness Information #1
Full Name:
Phone number:
Date of Birth:
Witness Information #2
Full Name:
Phone number:
Date of Birth:
Action Taken:
What action was taken:
Person Completing Form
Name:
Position:
Date:
Submit