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: