Employee Incident Report
Download a blank fillable Employee Incident Report in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Employee Incident Report with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2A
R
DMINISTRATIVELY
ESTRICTED
E m p l o y e e I n c i d e n t R e p o r t
Page 1 of 2
Date of Report:
Time:
Reporting School:
School Phone Number:
Name of Child:
D.O.B.:
Last
First
Middle
Sex:
Age:
Grade:
Teacher:
Parent(s)/Legal Guardian(s) Names:
Mailing Address:
Location of Home:
Home Telephone:
Work No. (Mother):
Work No. (Father):
Date of Alleged Incident:
Time:
[ ] a.m.
[ ] p.m.
Location of Alleged Incident:
Check all that apply:
Discourteous conduct involving a student by an employee:
[ ] Using inappropriate language
[ ] Making inappropriate comments of a nonsexual manner
[ ] Calling names insulting or humiliating a child
[ ] Shouting or cursing
[ ] Rude, boisterous play that adversely affect production, discipline, or morale of a student
[ ] Use of abusive, demeaning, degrading, or insulting language
[ ] Quarreling or inciting a quarrel
[ ] Other:
Describe in Student’s/Staff’s Own Words His/Her Account Of Event(s):
Full Name(s) of Potential Witness(es):
Phone Number(s):
Full Name of Alleged Offender:
Last
First
Middle
Check One:
[ ] BIE Employee
Position Title:
[ ] BIE Contractor/Consultant
[ ] Other (specify):
Full Name and Title of Mandatory Reporter:
Signature
:
Date:
(Required)
Full Name of School Principal/Administrator or Designee:
Signature
:
Date:
(Required)
Has Mandatory Reporter Requested Protection of His or Her Identity?
[ ] YES
[ ] NO
Initials of Mandatory Reporter:
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business