Please fully complete the form.
Location of Alleged Incident: _______________________________________________
Alleged Incident Date: __________________ Time: _______________
Name: ________________________________________________________________
Telephone No.: __________________
Home Address: _________________________________________________________
D.O.B.: _______________
ALLEGED INCIDENT INFORMATION
Reported by: _______________________________________________ Date: _______________ Time: _______________
Person Supervising: _______________________________________________
Describe where within building/location alleged incident occurred and how:
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Please describe alleged injury (Include part of body):
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Name/Address/Telephone of any Witnesses (Please indicate if none):
_____________________________________________________________________
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Was first aid rendered? □ Yes □ No
If yes, by whom/date/time: _______________________________________________
Did individual remain in school remainder of day/activity? □ Yes □ No
Describe first aid: _______________________________________________________
Did individual receive medical attention by a physician or hospital? □ Yes □ No
If yes, describe medical attention. If unknown, please state:
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Name/Address/Telephone # of physician or hospital:
_____________________________________________________________________
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EMERGENCY CONTACT INFORMATION
Person contacted/relationship: ____________________________________________________________
Address: _______________________________________________ Telephone No. __________________
Contacted by ______________________________________ Date: __________________ Time: __________________
If emergency contact was not contacted, please state reason:
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Completed by Name: _______________________________________________
Date: __________________ Title: __________________
Reviewed by Name: _______________________________________________
Date: __________________ Title: __________________
Adopted: January 23, 2012