Elementary School Incident Report Form Example – [Edit & Download]

Date and Time of Incident: February 24, 2025, at 10:15 AM
Location of Incident: Playground, Maple Elementary School
Person Reporting the Incident: Sarah Collins, Playground Supervisor
Details of Involved Individuals:

• Lucas Brown – Student, Grade 2
• Emma Wilson – Student, Grade 2

Witnesses:

• Natalie Ford – Teacher, Grade 2
• Jack Roberts – Playground Assistant

Description of Incident:
During recess, Lucas Brown and Emma Wilson were involved in a dispute over playground equipment. The disagreement escalated when Lucas pushed Emma, causing her to fall and scrape her knee.

Immediate Actions Taken:

• Both students were immediately separated to cool down.
• First aid was applied to Emma Wilson’s scraped knee by the school nurse.
• Lucas Brown was taken aside to discuss his actions and the importance of sharing and kindness.

Follow-up Actions:

• A meeting with both students’ parents to discuss the incident and explore strategies to prevent future conflicts.
• Additional monitoring of playground interactions, with a focus on teaching conflict resolution skills to students.
• A reminder session for all students about playground rules and the importance of respecting each other.

Signatures:

• Sarah Collins (Reporter)
• Michael Thompson (Principal)

Additional Notes:
Emma Wilson was comforted and returned to class after treatment; her parents were informed of the incident. Lucas Brown expressed remorse for his actions and participated in a restorative conversation with Emma. The school will continue to reinforce positive behavior and interactions among students to ensure a safe and nurturing environment.