Sample Incident Reporting Form Page 2

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Why do you think this occurred?
___________________________________________________________________________________________
Were there any witnesses? Yes
No
If yes, please provide their names:
___________________________________________________________________________________________
___________________________________________________________________________________________
Did a physical injury result from this incident? If yes, please describe.
___________________________________________________________________________________________
Was the targeted student absent from school as a result of the incident?
Yes
No
If yes, please describe
___________________________________________________________________________________________
Are there any notes, pictures, texts, screen shots or other evidence of the event(s) you are reporting?
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there any additional information you can add?
___________________________________________________________________________________________
___________________________________________________________________________________________
Thank you for reporting!
----------------------------------------------------------------For Office Use----------------------------------------------------------------
Received by: _______________________________________________________________________________
Date received: ___________________________________
Action taken: ______________________________________________________________________________
Parent/guardian contacted: ___________________________________________________________________
Circle one:
Resolved
Unresolved
Referred to: _____________________________________

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