Building Location Name (i.e. Green Elementary; District Office; Shady Glen High School)
Teacher, Custodian, Assistant, etc.
Administration, Food Service, Instruction, Maintenance, SPED, Transportation, etc.
Example: Field trip to the pumpkin patch, sporting event at school, en route/traveling
Please provide a brief description of the incident/injury.
Example: Left leg, right elbow, low back, head, left middle toe, etc.
Example: Bruise, cut, scratch, sprain, strain, fracture, etc.
Provide the name of the person you reported your incident to. If you did not report it, enter "Not Reported".
Provide witness name, or if none enter "None"