Incident Report Teacher/Staff Reporting Incident First Name Last Name Date of Incident MM DD YYYY Time of Incident Hour Minute Second AM PM Location of Incident Individuals Involved: #1 First Name Last Name #2 First Name Last Name #3 First Name Last Name #4 First Name Last Name Witnesses: #1 First Name Last Name #2 First Name Last Name #3 First Name Last Name Explain incident in detail: Describe Nature of Injury: Treatment administered by school personnel: Thank you! Please send witness reports (scans are fine) to kelly.disbennet@gca.life
