Common use of Incident Report Form Clause in Contracts

Incident Report Form. Cashmere School District Incident Report Form Child’s Name: Incident date: Time: Location: Report Written By: Date: Time: Staff, Xxxxxx Parents, Others Involved: Critical Incident? Y/N Administrator notified? Y/N Initials: Therapeutic Hold? Y / N  Property Destruction  Run  Escort  Assault  Sexual Acting Out  Seated  Self Injurious  Out of the ordinary  Medical  Behavioral  Medication  Other (describe):  Wall  Tool Kit (describe): Description of the incident: please include what was taking place prior to the incident (antecedents), what happened during the incident (in detail), and after the incident, as well as any injuries: (Please attach paper for additional information) Actions Prior To Incident: Actions During the Incident:

Incident Report Form. Cashmere School District Incident Report Form Child’s Name: Incident date: Time: Location: Report Written By: Date: Time: Staff, Xxxxxx Parents, Others Involved: Critical Incident? Y/N Administrator notified? Y/N Initials: Therapeutic Hold? Y / N  ❑ Property Destruction  ❑ Run  ❑ Escort  ❑ Assault  ❑ Sexual Acting Out  ❑ Seated  ❑ Self Injurious  ❑ Out of the ordinary  ❑ Medical  ❑ Behavioral  ❑ Medication  ❑ Other (describe):  ❑ Wall  ❑ Tool Kit (describe): Description of the incident: please include what was taking place prior to the incident (antecedents), what happened during the incident (in detail), and after the incident, as well as any injuries: (Please attach paper for additional information) Actions Prior To Incident: Actions During the Incident: