ROCK-WALWORTH COMPREHENSIVE FAMILY SERVICES, INC. HEAD START AND EARLY HEAD START® Serving Rock & Walworth Counties

INCIDENT REPORT *	Page 1 of ____
Type of Incident:	Choose an item.	Click here to enter text.
Reporter’s Name:	Click here to enter text.	Date of Report:	Click here to enter a date.
Reporter’s Status:	Choose an item.	Date of INCIDENT:	Click here to enter a date.
Click here to enter text.	Time of INCIDENT:	Hr	Min	AM/PM
Location of Incident:	Choose an item.

Witness 1 to Incident	Witness 2 to Incident
Name & Address:	Click here to enter text.	Name & Address:	Click here to enter text.
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Description of Incident (if injury, state extent & nature of injury and if medical attention was sought) :
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Reporter’s signature: ___________________________________________ Date: __________________ Original to Team Leader: Choose an item. Upon review, Team Leader’s Initials:_________ Date: ________
Copies to: Click here to enter text.

HH 9/2012