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High Meadow School
OCCURRENCE REPORT
To be completed by staff with “first knowledge.”
Use this form for:
Injuries requiring first aid or less
Injuries requiring transport to Emergency Department.
Behavioral Emergencies
General Info
Individual’s Name:
(Required)
First
Last
Date of Incident
(Required)
MM slash DD slash YYYY
Class/Events
(Required)
Time of Event
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Teacher Name
(Required)
First
Last
Witnessed or Reported By
Incident was
(Required)
Observed
Reported
By
(Required)
First
Last
Description of Incident
(Required)
911
Was 911 Called?
(Required)
Yes
No
Time Called
Hours
:
Minutes
AM
PM
AM/PM
Parent/Guardian notified by
First
Last
ER
Was the person sent to the ER
(Required)
Yes
No
Departed When
Hours
:
Minutes
AM
PM
AM/PM
Where to?
Mode?
If EMS or E.R., notify Health and Safety Coordinator and School Head for Q.A./Q.I.
Parent/Guardian Follow-up
Was Parent/Guardian Contacted?
(Required)
Yes
No
Method of Contact
Email
Phone
Text
Other
Name of parent contacted
First
Last
Called By
First
Last
Time Parent/Guardian Contacted
Hours
:
Minutes
AM
PM
AM/PM
Location
Location of Incident
(Required)
Assessment
Assessment: (Findings and Treatment)
Print name of Provider
First
Last
Tttle
Signature
Date
MM slash DD slash YYYY
Administrative Follow-up
Administrative follow-up/ Action Taken:
Reviewed at bi-weekly Safety Meeting:
Yes
Reviewed Date
MM slash DD slash YYYY
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