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Incident Report Form
Incident Report Form
Incident Report
Person Reporting Incident Info
Name of person reporting the incident
*
Address
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
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North Carolina
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Northern Mariana Islands
Ohio
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Pennsylvania
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South Carolina
South Dakota
Tennessee
Texas
Utah
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Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
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State
ZIP Code
Phone
*
Incident Information
Date of Incident
*
MM slash DD slash YYYY
Time of Incident
*
:
Hours
Minutes
AM
PM
AM/PM
Location of Incident
*
People Involved
*
Please list all parties involved and any contact information obtainable.
Witnesses
Please list all witnesses and any contact information obtainable.
Incident Details
Description of Incident
*
Give as much detail as possible.
Assessment of Injury
Please describe injuries if any.
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12-18
Average class size