Incident Reporting Form
Date Received
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Incident Report Follow Up
Counselor Follow Up needed
Counselor Follow Up Completed
No more action is needed at this time
Admin/Counselor - Submit
Admin Recording
Counselor Recording
Admin Notes
Counselor Notes
Example: resolution, parent contact, follow up etc.
Date of Incident
-
Month
-
Day
Year
Date
Time of Incident
Please Select
Before School on the bus
Before School
1st Period
2nd Period
Advisory
3rd Period
Lunch
4th Period
5th Period
6th Period
7th Period
After School
After School on the bus
Other
When did the incident occur?
Your Name
*
First Name
Last Name
ID Number
*
Grade Level
*
6
7
8
List the names of any people who saw or have information about the incident
Describe the details of the incident. Including names of people involved, what occurred, and what each person did and said, including specific words used.
*
Signature - your signature indicates that the above incident report is accurate and true to the best of your knowledge.
Submit
Should be Empty: