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United Collective Incident Report

indicates a required answer

The Student Incident Report is used to document any event that impacts a student’s safety, health, behavior, or well-being while participating in our program.

This form ensures accurate communication, proper response, and consistent documentation for leadership and families.

PURPOSE

The Incident Report exists to:

  • Document what happened in a factual and objective manner
  • Ensure appropriate care and follow-up for the student
  • Provide clear communication with parents/guardians
  • Identify patterns or safety concerns
  •  Protect students, staff, and the organization

WHEN TO COMPLETE AN INCIDENT REPORT

A report must be completed the same day when:

  • A student is injured or becomes ill

  • First aid is administered

  • A head injury occurs (always required)

  • A behavioral incident affects safety or learning

  • Bullying or peer conflict is reported

  • Property damage occurs

  • A student is sent home

  • Emergency services are contacted

Minor redirections that do not involve safety, injury, or parent contact do not require a full incident report (these may be logged in a behavior note).

REPORTING STANDARDS

All reports must be:

  •  Factual — describe only what was seen or heard
  • Objective — no opinions, assumptions, or diagnoses\Timely — completed before leaving campus that day
  • Confidential — shared only with appropriate leadership

Use clear language such as:
“Student tripped while walking and landed on knees”
Not:
“Student was being careless”

REQUIRED STEPS AFTER AN INCIDENT

  1. Ensure the student is safe and supervised

  2. Provide appropriate care (first aid, rest, nurse/parent contact)

  3. Notify the Campus Lead immediately for significant incidents

  4. Contact the parent/guardian when required

  5. Complete the Incident Report form

  6. Submit to leadership for review and filing

PARENT COMMUNICATION

Parents/guardians must be notified for:

  • Any injury to the head

  • Any injury requiring first aid beyond a small scrape

  • Illness requiring the student to rest or go home

  • Behavioral incidents that disrupt safety

  • Any situation the parent would reasonably expect to know

Documentation of the contact method and time is required.

CONFIDENTIALITY

Incident reports are confidential documents and must:

  • Be stored securely

  • Not be shared with unauthorized individuals

  • Never be discussed publicly or with other families

FOLLOW-UP

Leadership will review reports to:

  • Determine if additional action is needed

  • Identify safety improvements

  • Develop behavior or support plans if necessary

  • Maintain accurate records

GOAL

The goal of the Incident Report process is not punitive —
it is to ensure student safety, clear communication, and a supportive learning environment.
1. *

Campus Location:

 

 (1 required)
Litchfield Park-K12 The Legacy-Goodyear
The Gathering-Goodyear
2. *

Date of Report:

 
3. *

Report Completed By:

 
4. *

Role:
5. *

Student Name:
6. *

Date of Incident:
7. *

Time of Incident: 
 
8. *

Location (classroom, playground, hallway, etc.):
9. *

Type of Incident:

 (1 required)
Injury Illness
Behavioral Safety Concern
Bullying Property Damage
Other
10. *

DESCRIPTION OF INCIDENT

(Write factual, objective details only — no opinions)
11. *

WITNESSES

Name(s) of staff or students who witnessed the incident:
12. *

ACTION TAKEN:

 (1 required)
First Aid Provided Student Rested
Ice Pack Applied Parent/guardian contacted
Removed from activity Behavioral redirection
Sent Home Emergency services called
13. 

Details:
14. *

INJURY INFORMATION (IF APPLICABLE):

Body part affected:
Type of injury:

 (1 required)
Scrape Cut
Bruise Bump to head
Sprain Other
15. *

Was there visible swelling, bleeding, or loss of consciousness?

 (1 required)
Yes No
16. *

PARENT/GUARDIAN NOTIFICATION

Parent/Guardian contacted by:

 (1 required)
Phone Text
In Person Email
17. *

Time of contact: 
Person who made contact:

 

Summary of conversation:
18. *

FOLLOW-UP REQUIRED

 

 (1 required)
Monitor Student Incident Review with Leadership
Behavior plan Safety plan update
Facility repair needed No follow-up needed
19. 

Details:
20. *

Signature of Staff:
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
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