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Incident Report Form
Name of Student
*
Name of Facilitator
*
Type of Report
*
Date&Time
*
*
Class Designation
*
Location
*
Injured party
*
Description of Incident
*
Immediate Actions Taken
*
Immediate Actions Taken
Medicine given
None needed
Sent home
Sent for a short rest
Sent to the Hospital/Contacted Emergency services
Was the parent contacted?
*
Witnesses
*
Name and Signature
*
Signature
*
Date of Report
*
Submit