Incident Report Form
Please fill out this form and click submit.
Incident Date
*
Time
*
Name
*
Persons Age
*
Gender
*
Please select one option.
F
M
Select Option
F
M
Location
*
Were there any injuries?
*
Please select one option.
Yes
No
Select Option
Yes
No
Did the person refuse professional medical treatment?
*
Please select one option.
Yes
No
Select Option
Yes
No
Were the Police or EMTs contacted?
*
Please select one option.
EMT Yes
Police Yes
No
Select Option
EMT Yes
Police Yes
No
Which type of incident?
*
Please select one option.
Accident
Altercation
Disruptive Behavior
Fall
Harassment
Verbal Threat
Weapon Violation
Reckless Endangerment
Select Option
Accident
Altercation
Disruptive Behavior
Fall
Harassment
Verbal Threat
Weapon Violation
Reckless Endangerment
Description of Incident
*
Were the parents notified?
*
Please select one option.
Yes
No
Unable to contact
Select Option
Yes
No
Unable to contact
Witness/Witnesses
*
Name of person submitting report
*
Submit
Description
Please fill out this form and click submit.
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