Incident Report Form - German International School New York

Incident Report Form / Vorfallsmeldung

Required

Date and Time:required

Date of Incident: required

Must contain a date in M/D/YYYY format

Name:

Sex:

Date of Birth:required

Must contain a date in M/D/YYYY format

Address:

Phone:

Student

Parent

Staff

Visitor

Name of Parent/Guardian (if minor):

Address:

Description of the incident in detail (include what the injured person was doing at the time):required

What was the injury?required

Where did the injury occur? (Please be as specific as possible)required

Emergency procedures followed at time of incident:

Where was the injured person taken

Nurses Office

Hospital ER

Doctor's Office

By whom?

Person the school notified:

When:

By whom?

Parent's response:

Comments:

Witnesses (you may wish to attach signed statements)required

Was the injured person participating in an activity at the time of incident:

Any equipment involved in the injury?

Signed:

Title:

More notes: