Inhalant Abuse Incident Report Form
Use this form to report and document any incidents involving inhalant abuse. Please provide as much detail as possible to ensure appropriate follow-up.
Date and Time of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Location of Incident
*
Person(s) Involved (Name and Role)
*
Age of Person(s) Involved (if known)
Witnesses (Name and Contact Information)
Detailed Description of the Incident
*
Type of Inhalant(s) Suspected or Known to Be Used
*
Please Select
Glue
Aerosol Spray
Solvent
Gas (Butane, Propane, etc.)
Nitrous Oxide
Other
Immediate Actions Taken
*
Recommendations or Follow-Up Actions Needed
Name of Person Reporting the Incident
*
First Name
Last Name
Role/Position of Person Reporting
*
Contact Information of Person Reporting (Phone or Email)
*
Signature of Person Reporting
*
Submit Report
Submit Report
Should be Empty: