Incident Report

Document IDINCIDENT1TitleIncident ReportPrint Date9/15/22
Revision1.0Prepared ByOperations and Governance CircleDate Prepared9/15/22
Effective Date9/15/22Reviewed By Operations and Governance CircleDate Reviewed9/15/22
Approved ByOperations and Governance CircleDate Approved9/15/22


  1. Once the situation is non-emergent, a witness should make a copy of this form on the drive, and complete the report. Witness can either print and complete a paper copy, or fill it out electronically to print and delete for confidentiality.
  1. An adult witness should complete this form. If there was no adult witness, an adult should complete this form using direct quotes from a student witness whenever possible.
  1. Once the form is complete, make a copy for every student involved, and send it home to the family.
  1. Give the original form to Kate or Stefano to file in the Incident Report Binder.
  1. If you completed electronically, please delete the file so that we can maintain confidentiality.
Milestone Democratic School
Incident Report
Students Involved
Person Completing Form
What happened from witness perspective?

Actions Taken (mark any/all actions taken):

Parent Notified

Further Medical Action Taken

Restorative Justice Referral Made
By Whom:
Last updated bySean Anderson on September 28, 2022
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