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LA Incident Report
To be used for reporting an accident or incident involving students, parents, visitors, etc. Copies are to be submitted to Bob Kramer and Frank Mastrangelo. Please scroll down (bar appears on mouse over) to complete all items requested on this form.
Date of Incident
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(mm/dd/yyyy)
Time of Incident
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Person Submitting Report
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Last Name, First Name, Phone
Email
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Location of Incident
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Immediate Action Taken
Please Select…
First Aid Treatment
Sent to Dean's Office
Taken Home
Sent to Hospital
Referred to Doctor
Name of Injured
Last Name, First Name
Parent Name(s)
Last Name, First Name
Home Address
Street, City, State, Zip
Daytime Number
Home Phone
Incident Description
Weather, type of incident, details, etc.
If Vehicle Accident: Vehicle Make(s), Year(s), license plate(s)
Drivers Names, Phone Numbers
Person(s) in charge at time of incident
Notification
Parent
Guardian
Doctor
Nurse
Teacher
Other
If other, please name
Last Name, First Name
How notified, when, by whom
ex. By cell, 7:00 p.m. by J. Smith
Witnesses
Last Name, First Name, Address, Phone
Corrective Action?
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What, if any, corrective actions will be taken?
If no action will be taken, please explain.
Please provide an email address where we can send a link to your current form.
Email Address :