Non Injury Incident Report

IMPORTANT: Fill out this report only after the school adminstrator (Daniel Deyling) has been notified at (619) 985-3120

Name

Age

Sex

Date of Incident

Time of Incident

Date of Report

Time of Report

Status

Grade

Type of Incident

Make #1

Model #1

Year #1

Make #2

Model #2

Year #2

Make #3

Model #3

Year #3

Other Location

Other Weapon

Actions Taken

Other Action

Other Agency Info - Name

Other Agency - Phone

Other Agency - Badge

Other Agency - Agency

Other Agency - Report Number

Comments

Actions Taken / Suggested to Prevent Incident in the Future

Event Name

Location

Leaders Involved

Leaders Phone Number

Other Witness Names

Other Witness Phone Numbers

Student's Address

Parent/Guardian Name

Parent/Guardian Phone Number

Preparer Name

Role at Time of the Incident

CAREFULLY REVIEW FOR COMPLETENESS BEFORE SUBMITTING REPORT TO ADMINISTRATION FOR REVIEW

Preparer Signature

Insert signature here

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