board protection
Date:_______________________
INCIDENT REPORT - SCHOOL EMPLOYEE/BOARD PROTECTION PROGRAM Yell Danville School District: ___________________________________ County: _______________________ Superintendent: __________________________________ Telephone: ____________________
Currently associated with school district in what capacity? Certified Employee
Secretary
School Nurse
Student Teacher
Teacher Aide
Substitute Teacher
Authorized Volunteer
School Board Member
Other
Student
Date of Claim or Incident: _____________________________
Time: ________________________
Where incident occurred: _________________________________________________________________
Brief description of incident: _______________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Description of injuries or damage: ___________________________________________________________ _______________________________________________________________________________________ Name and Address of Person(s) claiming injury or damage:
Names of witness(es):
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Mail two copies of this report to: Dewane Hendrix, Coordinator School Insurance State Education Buildings, Room 102-B 4 Capitol Mall Little Rock, AR 72201
INCIDENT REPORT - SCHOOL EMPLOYEE/BOARD PROTECTION PROGRAM Yell Danville School District: ___________________________________ County: _______________________ Superintendent: __________________________________ Telephone: ____________________
Currently associated with school district in what capacity? Certified Employee
Secretary
School Nurse
Student Teacher
Teacher Aide
Substitute Teacher
Authorized Volunteer
School Board Member
Other
Student
Date of Claim or Incident: _____________________________
Time: ________________________
Where incident occurred: _________________________________________________________________
Brief description of incident: _______________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________
Description of injuries or damage: ___________________________________________________________ _______________________________________________________________________________________ Name and Address of Person(s) claiming injury or damage:
Names of witness(es):
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
_____________________________
Mail two copies of this report to: Dewane Hendrix, Coordinator School Insurance State Education Buildings, Room 102-B 4 Capitol Mall Little Rock, AR 72201
