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

Date and Time of Incident: March 10, 2025, at 1:30 PM
Location of Incident: Cafeteria, Riverside High School
Person Reporting the Incident: Laura Mitchell, Cafeteria Supervisor
Details of Involved Individuals:

• James Peterson – Student, Grade 11
• Mia Cheng – Student, Grade 11
• Carlos Gomez – Student, Grade 11

Witnesses:

• Derek Simmons – History Teacher
• Sophie Reynolds – Cafeteria Worker

Description of Incident:
During lunch break, a heated argument occurred between James Peterson and Mia Cheng over seating arrangements, which escalated when Carlos Gomez tried to intervene. The situation intensified, resulting in a scuffle that knocked over a table and spilled food.

Immediate Actions Taken:

• The cafeteria was immediately cleared to deescalate the situation.
• The school counselor was called to mediate the conflict shortly after the incident.
• All involved students were taken to the principal’s office for further discussion and disciplinary action as necessary.

Follow-up Actions:

• Schedule individual counseling sessions for James, Mia, and Carlos to address personal conflicts and develop better conflict resolution strategies.
• Hold a school assembly to reinforce the importance of respectful communication and peaceful conflict resolution.
• Review and possibly revise the school’s policy on handling disputes and ensure all students are familiar with these guidelines.

Signatures:

• Laura Mitchell (Reporter)
• Dr. Harold Lee (Principal)

Additional Notes:
No serious injuries were reported; however, the incident caused significant disruption and distress among other students. The parents of James, Mia, and Carlos were contacted and informed of the incident and the school’s steps to address the situation. Additional supervision will be implemented in the cafeteria during lunch hours to monitor and quickly address any potential conflicts.