Student Incident Report Please enable JavaScript in your browser to complete this form.Incident Details An incident concerning your child occurred at the center. Date / Time of the Incident *DateTimeStudent Name *FirstLastLocation of the IncidentPlaygroundGymClassroomDining RoomActivity RoomSanctuaryOtherDescription of the Incident *Parties Involved Names of People Involved in the IncidentSpecific names of other students involved will not be disclosed on the incident report to prevent retaliation Was anyone injured during the incident?YesNoDescription of InjuriesWas any property damaged during the incident?YesNoDescription of Property DamageWere any actions taken during the incident?Police were notifiedMedical treatment was providedBoth police and medical were involvedNo action was takenFirst aid given at the facility: *ComfortPressure on the woundElevationCold PackWashingBandage/ Band aideDescription of Action TakenReporting Information Names of Witnesses to the IncidentName of Staff Person Reporting the Incident *FirstLastName of Parent/ Guardian that was informed *FirstLastSubmit
