School Incident Report
Report Date:
State:
Severity:
SECTION 1: INCIDENT DETAILS
Student: ________________ Grade: ________
Teacher: ________________
Date: ________________ Time: ________
Location: ________________________________
Severity: ________________
Description:
________________________________
Immediate Actions Taken:
________________________________
SECTION 2: NOTIFICATIONS
Parent / Guardian: Not yet contacted
Administrator: Not yet notified
SECTION 3: PEOPLE INVOLVED
SECTION 4: WITNESSES
No witnesses reported.
SECTION 5: ROOT CAUSE ANALYSIS
Contributing Factors:
________________________________
Root Cause:
________________________________
Corrective Actions:
________________________________