INCIDENT REPORT FORM

This form is to be used to report an incident during classes or events at our studio.

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 *

Studio A

Studio B

Studio C

Studio D

Reception

Waiting room

Offsite

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/person's parent or relevant contact notified? *

Yes

No

Any other information that needs to be noted