[DC GOVERNMENT] Learn24 Incident Report Form

Grantees are required to report any serious incident that results in injury of a program participant and/or in contact of emergency personnel. The report of the incident must be made within one (1) business day of the incident by completing an Incident Report Form and a copy of the report must be sent to the Grant Manager within three (3) business days. The Grantee must keep the report on file and make it available upon request.

Reported by:

Name

Date of Report

Organization

Phone Number

Incident details:

School where Incident Took Place

Description of Incident (Describe facts of the events. Consider things leading up to the incident, environmental conditions, any injuries, damage to equipment or materials, take photos if appropriate)

Plans and/or Actions taken after the incident

Upload File(s) - include all relevant documents such as internal incident report, statements, police report, or relevant documents.

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Information of parties involved or witnesses (Name, phone, email address, insurance, etc.)

Additional File(s) - include all relevant documents such as internal incident report, statements, police report, or relevant documents.

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Additional File(s) - include all relevant documents such as internal incident report, statements, police report, or relevant documents.

Click Here to Upload