Student Incident Report Template

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Student Incident Report Template

A student incident report is completed following an event involving a student to document what occurred. It records when and where the incident took place, what happened, who was involved, and the responding actions, if any. Once prepared, the form is reviewed by school administration to determine whether disciplinary action or other follow-up measures are necessary.

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Last updated August 27th, 2025

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A student incident report is completed following an event involving a student to document what occurred. It records when and where the incident took place, what happened, who was involved, and the responding actions, if any. Once prepared, the form is reviewed by school administration to determine whether disciplinary action or other follow-up measures are necessary.

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When to Use a Student Incident Report

  • On-campus accidents and sports injuries
  • Loud music or parties in university or college dormitories
  • Disruptive behavior, vandalism, bullying, or fighting
  • Medical emergencies (e.g., allergic reactions, seizures)
  • Suspected or confirmed use of drugs, alcohol, or weapons

State Reporting Requirements

Some states require school staff to report specific student-related incidents, such as those involving drugs or firearms. Reporting obligations vary by state and incident type, but often require notification to the following parties:

  • School administrator
  • Parent or guardian
  • State department of education

Additional information on reporting obligations can be obtained from the local school board and the applicable state department of education.

Sample

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STUDENT INCIDENT REPORT

INDIVIDUAL FILING REPORT

Full Name: [FILER NAME] Tile/Role: [FILER ROLE/TITLE (E.G., WITNESS)]

Signature:                                                               Date: [MM/DD/YYYY]

STUDENTS INVOLVED

  1. Full Name: [NAME] Date of Birth: [DATE]
    Student ID No.: [STUDENT ID # (IF APPLICABLE)]
  2. Full Name: [NAME] Date of Birth: [DATE]
    Student ID No.: [STUDENT ID # (IF APPLICABLE)]
  3. Full Name: [NAME] Date of Birth: [DATE]
    Student ID No.: [STUDENT ID # (IF APPLICABLE)]
  4. Full Name: [NAME] Date of Birth: [DATE]
    Student ID No.: [STUDENT ID # (IF APPLICABLE)]

INCIDENT DETAILS

Date of Incident: [MM/DD/YYYY] Time: [TIME] ☐ AM ☐ PM
Location: [INCIDENT LOCATION]
Describe the Incident: [DESCRIBE INCIDENT]
Describe the actions taken in response: [DESCRIBE RESPONDING ACTIONS]

PEOPLE WHO WERE NOTIFIED

Specify the people who were notified of the incident:

☐ Parent/Guardian: [PARENT/GUARDIAN NAME] Date and Time: [DATE AND TIME]
☐ Hospital/EMT: [HOSPITAL/EMT NAME] Date and Time: [DATE AND TIME]
☐ School Admin.: [SCHOOL ADMIN. NAME] Date and Time: [DATE AND TIME]
☐ Law Enforcement: [LAW ENFORCEMENT NAME] Date and Time: [DATE AND TIME]

If law enforcement was contacted, was a report filed? ☐ Yes ☐ No
What is the report number? [POLICE REPORT NUMBER]

INJURIES / MEDICAL SERVICES

Was anyone injured? ☐ Yes ☐ No
If yes, describe the injuries: [DESCRIBE INJURIES]

Was medical treatment provided? ☐ Yes ☐ No ☐ Refused
If yes, where was medical treatment provided? ☐ On site ☐ Hospital ☐ Other: [OTHER]

STUDENT SCREENING

Did the student appear intoxicated? ☐ Yes ☐ No | If yes, please answer the following:

  1. Was the student carrying any medications? ☐ Yes ☐ No
  2. Was the student asked if they were on any medications? ☐ Yes ☐ No
  3. Did the student have any signs of physical injury? ☐ Yes ☐ No
  4. Was the student out of control or physically violent to self or others? ☐ Yes ☐ No
  5. Was a breathalyzer administered? ☐ Yes ☐ No | If yes, record the results: [BREATHALYZER RESULTS]

Additional observed health concerns: [DESCRIBE OTHER HEALTH CONCERNS OBSERVED]