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Employee Name: required |
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Workplace: required |
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Position: required |
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 INCIDENT DETAILS |
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Date of Incident: required |
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Time of Incident: required |
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| Workplace location where incident occurred: required |
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Type of Incident: required |
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Do you know the identity of the student who carried out the incident? required |
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Is this an Intensive Needs student with an Inclusion and Intervention Plan? required |
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| Please describe the incident (what happened before, during and after): required |
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| INJURY/PROPERTY LOSS/DAMAGE |
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Were you injured during the incident? required |
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Did you suffer any property damage/loss? required |
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Did you require medical attention? required |
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| Please describe what may be helpful in supporting you in your role: required |
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Principal/Supervisors email address: required |
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By typing in your name (your “eSignature”), you accept and consent to be legally bound by this document’s statements, terms and conditions as if this document was signed by you in writing with pen on paper. You agree that no third party or other means of verification is necessary to validate your eSignature and that the lack of such third party or other means of verification will not in any way affect the enforceability of this document.
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By typing in your name (your “eSignature”), you accept and consent to be legally bound by this document’s statements, terms and conditions as if this document was signed by you in writing with pen on paper. You agree that no third party or other means of verification is necessary to validate your eSignature and that the lack of such third party or other means of verification will not in any way affect the enforceability of this document.
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By typing in your name (your “eSignature”), you accept and consent to be legally bound by this document’s statements, terms and conditions as if this document was signed by you in writing with pen on paper. You agree that no third party or other means of verification is necessary to validate your eSignature and that the lack of such third party or other means of verification will not in any way affect the enforceability of this document.
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