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Paid Leave Request

Incident Report Form (2025)

"*" indicates required fields

Your Name:*

Your Position/Title:*

Your Email Address:*

Your Phone Number:*

Nature(s) of the Incident You are Reporting:*

Injury

Student Conduct

Interpersonal Conflict

Mental Health Concern

Property Damage

Improper Use of Property

Abuse

Other (Please Describe)

If you selected Other, please describe here:

Date of Incident:*

Time of Incident:*

Location of Incident:*

Which Program did the incident take place during?*

How many individuals were involved in the incident?*

Please enter a number from 1 to 5.

Information About Person #1

Name (Person #1):*

Relationship to SPARC:*

What was Person #1's role in the incident?*

Are you concerned about this person's mental health?*

Information About Person #2

Name (Person #2):*

Relationship to SPARC:*

What was Person #2's role in the incident?*

Are you concerned about this person's mental health?*

Information About Person #3

Name (Person #3):*

Relationship to SPARC:*

What was Person #3's role in the incident?*

Are you concerned about this person's mental health?*

Information About Person #4

Name (Person #4):*

Relationship to SPARC:*

What was Person #4's role in the incident?*

Are you concerned about this person's mental health?*

Information About Person #5

Name (Person #5):*

Relationship to SPARC:*

What was Person #5's role in the incident?*

Are you concerned about this person's mental health?*

Detailed Summary of Incident:*

Detailed Description of Injury (if injury occurred):*

Were there any subsequent actions taken?*

Details of Subsequent Action:*

If this incident involved a student, did you speak with a parent or guardian about the incident?*

Please describe that conversation here:*

Was medical treatment provided?*

Were there any witnesses to the incident?*

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Name

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