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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:
________________________________

Preventive Measures:
________________________________

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