Date                     

 

Time                       

 

Staff Person                                           

Where did this incident occur?                                                                                                                

 

Person(s) involved:                                                                                                                

 

What occurred?:                                                                                                               

 

Action steps are taken:                                                                                                               

 

Anyone injured?            If yes, the person(s) injured:                                       

 

Type of injury:                                                                                                               

 

Treatment:                                                                                                               

 

Parent/Guardian notified?      Yes      No       Time notified:                                                

 

Disciplinary (if any) measures taken:                                                                                                               

 

Comments:                                                                                                                

 

 

Report filed by:                                                           Supervisors initials: