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Incident Report Form: School Program Providers
When significant episodes take place in DCPS schools under the supervision of a School Program Provider, the Central Office must be informed through this form.
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Name of School Program Provider, (example, DC Kids)
Your answer
Name of DCPS school at which the incident took place
Your answer
Name of individual submitting this form
Your answer
Title of individual submitting this form
Your answer
Email of individual submitting this form
Your answer
Phone number of individual submitting this form
Your answer
Date and time of incident
MM
/
DD
/
YYYY
Description of incident (please provide as much detail as possible in your description)
Your answer
Name of witnesses, if any, of the incident
Your answer
Name of the school-based DCPS staff notified of the incident
Your answer
What follow up has been done? (For example, were parents notified, MPD called, medical attention received)
Your answer
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