Incident Report

Student First Name *

Student Last Name *

Incident Date *

Were the local authorities contacted? *

Yes
No

List the Responding officials:

List the agencies that received a report on the incident: *

Summarize the Facts *

Report any injuries:

List any witnesses:

Describe any safety measures taken:

Describe any media coverage:

How do you know the student?

I am the student
I am hosting a student
I am a teacher or school official
I am a Rotarian
I am in a position of authority
I am a friend or acquaintance of the student
I am related to the student
I do not know the student

Your Name:

Your Email:

Your Phone:

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Incident Report