Incident Reporting

Use the below form to report incidents involving employees or students to track trends to better protect us all.

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Incident Report Form

Report Date:

Your Full Name:*

Your Position:

Your Phone:*

Your Email:*

Incident Involvement:

Incident Type:

Location of Incident:

Other Location:

Incident Date and Time:

Identify Involved Person(s):

Involved Person(s) Phone:

List incident details (who was involved, when, where, why, how, what was said/done, etc.):

Was the victim injured?:

Were medical services rendered?:

If yes, explain medical services rendered:

Contact information for medical professional:

Was a weapon involved?:

If yes, what type of weapon?:

Does person have a history of violence?:

Describe Violence History:

Does person have any prior criminal or disciplinary problems?:

Describe History:

Is person struggling with or facing any other known stressors?:

Describe Stressors:

Help us prevent spam reports:*

23235 N COUNTY HIGHWAY 22
CANTON IL 61520
1-800-DEGREES | (309) 647-4645