Date and Time of Incident: Location of Incident:
Parent’s Phone Number: Alternate Parent’s Phone Number:
Name of Student: Address of Student:
Please write a brief description of what occurred:
Please list any eyewitnesses to what occurred (attach statements, if any, to this report):
Please indicate what procedure was taken to resolve the incident:
___________________________________________
Signature / Date
Approved: 7/15/2019 Reviewed: Revised:
