Incident Report Form

WARNING: You must not provide copies to anyone other than SIP and the school board or NSCC. Under no circumstances can copies be shown or provided to parents or injured parties.

  Are you the injured party?
 
 
 
1 Name of Regional Center for Education or Community College
 
2 Name of School or Campus
 
3 Incident Site (only if other than School or Campus)
 
4
 
 
5 Gender
 
 
6 Has the Parent/Guardian been contacted?
 
 
7 Is the Injured Person a Student? 
 
Yes   No    
 

For accidents involving students that have resulted in an injury and/or an
ambulance bill, please ensure that the parents are aware of SIP's Student
Accident coverage

8 If the Injured Person is a Student, what is their:
 
- -           

(yyyy)
(mm)
(dd)
    
    
 
9
 
 
10
 
 
11
  Visitor     Employee     Volunteer   
 
 
 
12
 
- -        

(yyyy)
(mm)
(dd)
  DAY OF THE WEEK
     (11:59)
 
13 Were person(s) injured?
 
 
14 Was others' property damaged?
 
 
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