Home and Hospital
Teaching
Security Incident Report
To be completed when involved in or
witnessing any behavior that threatens your person or property or
interferes with the instructional program.
Complainant
Information
Name
Address
Telephone (Home and
Work)
Incident Report
Perpetrator's/Accused Name
Relationship to
Student
Date/Time Incident
Occurred
Place Incident
Occurred
Name of Supervising
Adult
Witness One:
(Name, Address, Telephone)
Witness Two:
(Name, Address, Telephone)
Description of Incident
Include the
following:
- If there was
an assault, theft, or verbal confrontation.
- Damages to person or possessions.
- Condition of all involved.
- Were parents notified?
- Were police notified?