Incident Report Employee Submitting Incident Report * First Name Last Name Email * Phone * (###) ### #### Date of Incident * MM DD YYYY Time of Incident * Hour Minute Second AM PM Name of Injured * First Name Last Name Age * Location of Incident * Person in Charge when Incident Occurred * First Name Last Name Description of Incident * Did you administer first aid? Yes No Did you send injured to school office? Yes No Did you send injured home with parent/guardian? * Yes No Did you refer the injured to medical doctor? * Yes No Did you send the injured to the hospital? * Yes No Did you notify the parent/guardian? * Yes No Did you notify the principal? * Yes No Did you notify the teacher? * Yes No Did you notify the coach? * Yes No Did you notify the medical doctor? * Yes No Comments about immediate action taken or individual(s) notified * Witness 1 Name First Name Last Name Witness 1 Phone Number (###) ### #### Witness 2 Name First Name Last Name Witness 2 Phone Number (###) ### #### Thank you!
