|
Page 3 of 4
APPENDIX
B
INCIDENT
REPORT
Date and time of incident(s):
Name of writer:
Location of incident(s):
This incident is a minor infraction or major infraction (circle or
highlight)
Individual(s) involved in the incident:
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
Objective description of the incident (please be concise, accurate
and non-judgmental):
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
________________________________ ________________________________
Names of individuals who observed the incident:
________________________________ ________________________________
________________________________ ________________________________
Disciplinary action which was taken (if applicable):
________________________________ ________________________________
________________________________ ________________________________
Signature of writer: ________________________
Date: ____________________
|
