Incident Report

Document IDINCIDENT1	TitleIncident Report	Print Date9/15/22
Revision1.0	Prepared ByOperations and Governance Circle	Date Prepared9/15/22
Effective Date9/15/22	Reviewed By Operations and Governance Circle	Date Reviewed9/15/22
	Approved ByOperations and Governance Circle	Date Approved9/15/22

Process:

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.

2. 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.

3. Once the form is complete, make a copy for every student involved, and send it home to the family.

4. Give the original form to Kate or Stefano to file in the Incident Report Binder.

5. If you completed electronically, please delete the file so that we can maintain confidentiality.

Milestone Democratic School

Incident Report

Date
Time
Students Involved
Witnesses
Person Completing Form

What happened from witness perspective?

Actions Taken (mark any/all actions taken):

	Parent Notified Notes:
	Further Medical Action Taken Notes:
	Restorative Justice Referral Made By Whom: