Risk Management Report Form
Please contact the Risk Management Department at 913-359-5170 for any serious Risk Management concerns. If you are unable to reach them, please leave a message or text and they will get back with you as soon as possible.
Reporter - Please write your first and last name. You may submit anonymously if you wish by putting "Anonymous" in both fields.
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First Name
Last Name
Date of Incident
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Approximate Time of Incident
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Hour Minutes
AM
PM
AM/PM Option
Specific Location of Incident
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(ex. Clemens Zone 1 Living Room, House 4 Kitchen, Nova Classroom
Person(s) Supported Involved- First and Last Name (Click the plus sign to add more names)
Staff Involved- First and Last Name (Click the plus sign to add more names)
Describe Incident
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of
Name of Person filling out the Form
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First Name
Last Name
Submit
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