Student Incident Reporting Form

STUDENT INCIDENT REPORTING FORM

This form is to report any student incident that is not an injury (may or may not be behavior related). Examples include bullying, physical aggression, inappropriate language, toileting accidents, and property destruction or disruption to the program by the student. This also includes any incident where law enforcement or licensing is contacted. If a team member, parent, or school administrator notices a behavior that is concerning or needs correction, use this form to document. Parent requests for special care/needs for a student in the program should also be reported on this form.

INSTRUCTIONS FOR COMPLETING THIS FORM:

1. Complete all sections of the form.

2. At the end of the form, click the button labeled "Please click here to review the information and print a copy of this form prior to submission."

3. Review and print a copy of the form. Then click "continue" to submit the form.

4. Use printed copy to review with parent and obtain signature.

5. Place paper copy of form with parent signature in file at site.

For questions or help with the form, please contact your immediate supervisor.
(HubSpot Hidden Field) Student Injury Reporting Form
- Name of Student:
  
  First NameLast Name
- Student Date of Birth
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearStudent Date of Birth
- Student Age
  Student Age
- Gender of Student
  
  Other
- Grade of Student
- Name of Student's Parent:
  
  First NameLast Name
- Email of Student's Parent:
  example@example.com
- Phone Number of Student's Parent
  Please enter a valid phone number.Format: (000) 000-0000.
- Date of incident
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Time of incident
  
  Hour Minutes
  
  AM/PM Option
- Incident location: For example, classroom, cafeteria, playground, etc. If other, please specify below.
- Please select the STATE where the Incident occurred:
- Please select the DISTRICT where the Incident occurred:
- Please select the SITE LOCATION where the Incident occurred:
- Type of Problem Behavior/Incident
- Please describe what occurred and be as specific as possible. (NOTE: Include only the name of the child receiving the incident report)
- Potential Team Member Witnesses - List all persons who may have knowledge of this situation
  Use full names
- Please provide any other relevant details. If none, type N/A.
- Consequences Used for this Incident
- Time of discussion
  
  Hour Minutes
  
  AM/PM Option
- Time child was picked up
  
  Hour Minutes
  
  AM/PM Option
- Date of parent conference request
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Date of Pause in Program
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Return Date to Program After Pause
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Date of Termination from Program
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- List the name of the parent/guardian contacted, the date and time of the call, and the name of the AlphaBEST team member who made the call.
  Required for ALL incidents
- Upload Any Additional Documentation
  
  Cancelof
- Name of person submitting this Incident Form
  
  First NameLast Name
- Site email (use official program/site email only, do not use personal email)
  Use your AlphaBEST email only (example@alphabest.org)
- Signature of person submitting the form
- AlphaBEST seeks to provide an environment conducive to positive child growth and development. Parents will be notified in writing of any major infraction. Should AlphaBEST deem any behavior harmful to any child or adult, immediate notification will be given to the parent/guardian for temporary suspension and/or permanent expulsion based on the severity of the behavior.
  
  *NOTE: AlphaBEST reserves the right to immediately suspend or terminate a child based on the severity of the offense. There are no refunds for suspension or termination due to unacceptable behavior.
- Parent Signature (AFTER REVIEWING WITH PARENT):
- Date of Parent Signature:
- Should be Empty: