INCIDENT REPORT FORM

This form is to be used to report an incident during classes or events at Pinnacle Performing Arts

Name of Person Completing Form *

Name of Student/Person Incident Relates to *

Name of any Witnesses that saw the incident *

Teacher/Supervisor at time of Incident *

Class/Event where Incident occurred *

Location of Incident *

Small Studio

Large Studio

Aerial Studio

Office

Kitchen

Hallway

Offset

Other

Brief Description of Incident *

Did the student/person sustain an injury as part of the above incident? *

Yes

No

What was the Injury

Was any First Aid provided *

Yes

No

What treatment was provided *

Did the student/person return to what they were doing following the incident *

Yes

No

Was the Student/Persons Parent or relevant contact notified *

Yes

No

Any other information that needs to be noted