Fine and Performing Arts Academy

Incident Statement
Name: ________________________________________ Todays Date: ___________________________
Circle one: Student / Teacher / Staff Birth Date: ________________Grade: _________
What happened? Be specific. (Include Names)
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Where did this happen? ___________________________________________________________________
When did this happen? (Date & Time)
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Who else witnessed what happened?
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When & why did this problem first occur?
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Date Received: _______________________
Received By: ____________________
Action Taken:
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side, if needed

Fine and Performing Arts Academy

Statement (Continued)

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