2024-2025 Incident Reports

For emergencies, dial 911. This form is not intended for incidents that pose an immediate threat to health or safety. If you need assistance with filing or completing this report, please review the Manual and consult your supervisor.

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Reporter Information

Please provide your details below. This information is essential for us to follow up on the incident report effectively and maintain accurate records.

Reporter Name:*

First Last

Title/Position:*

Contact Info:*

Report Details

Provide all relevant information about the incident. Following these directions carefully ensures that we have a detailed and accurate account for our records.

Select the type of incident report:*

If you are unsure whether to file a Formal Incident Report or a Minor Incident, please check with your Supervisor or Program Manager/Coordinator.

Formal Incident Report - Legal documentation of an event.

Minor Incident (Small Scale) - Occurrences that should be kept on the JBS radar, but do not require a formal report.

Employee Injury - Any injury sustained by an employee, regardless of severity.

Indicate the individual(s) involved in the incident:*

Employee - Incident involved one or more Joffrey Ballet School employees.

Student - Incident involved one or more students.

Other - Incident involved visitors or other non-employee individuals.

How many staff members responded to the incident?*

Please enter a number from 0 to 10.

Staff Member 1 Name:

First Last

Staff Member 2 Name:

First Last

Staff Member 3 Name:

First Last

Staff Member 4 Name:

First Last

Staff Member 5 Name:

First Last

Staff Member 6 Name:

First Last

Staff Member 7 Name:

First Last

Staff Member 8 Name:

First Last

Staff Member 9 Name:

First Last

Staff Member 10 Name:

First Last

Date of Incident:*

Time of Incident:*

Program Type:*

Please select the program type associated with this incident:

Summer Intensive - For incidents occurring during our Summer Intensive programs.

Other Programs - For incidents related to any other programs, including Year Round and any other activities such as workshops.

Program Options:*

Please Specify Program/Activity:*

Select Location:*

Select Intensive:*

Specify Program:*

Ballet

Jazz & Contemporary

Specify Program:*

Cirque Arts

Jazz & Contemporary

Specify Program:*

JoffreyRED

Joffrey West

Select Location:*

Location of Incident:*

Studios

Residence Hall

Performance Venue

Other (Ex: Dorm Activities)

Specify Location of Incident:*

Select Category of Incident:*

Provide Additional Information:*

Injury Type:*

Illness Type:*

Concern Type:*

Conflict Type:*

Was this incident added to the health log?*

Yes

Was first aid given?*

Yes

Was emergency care required?*

Yes

Was immediate support provided?*

Yes

Were they referred to a professional?*

Yes

Were disciplinary actions taken?*

Yes

Was this resolved on-site?*

Yes

Behavioral Violation:*

Select all that apply

Bullying

Disruptive Behavior

Inappropriate Conduct

Physical Altercation

Threatening Behavior

Verbal Harassment

Other

Code of Conduct Violation:*

Select all that apply

Age:*

Please enter the age of the individual involved.

Please enter a number from 1 to 100.

Identify Individuals Involved

Please list all individuals associated with this incident in the categories below, including witnesses and non-students. Do not include yourself, other staff members, or police/emergency officials in this section. You will have the opportunity to provide that information in the next section, if applicable. For each individual or group of individuals, specify their role by selecting whether they are a student, employee, or other. This detailed categorization helps ensure our records accurately reflect the incident's context and all parties involved.

For each category, please provide names and select the appropriate designation (Student, Employee, Other) to indicate their relationship to the school or event.

Reporter: The person or people who reported this incident. Include this information only if it was reported to you by someone else.

Reporter Information:

Enter the name(s) of the individual(s) who reported the incident. If there are multiple reporters, please list all names separated by commas.

Alleged: The person or people alleged to have committed the violation(s).

Alleged Violator(s):

List the name(s) of the individual(s) alleged to have committed the violation. If more than one person is involved, separate their names with commas.

Witness: Any individuals who witnessed the incident but were not directly involved.

Witness Details:

Provide the name(s) of any witnesses to the incident. Include multiple names by separating them with commas if necessary.

Incident Details

Note: We have updated the sections of our incident report form to help clarify and organize the information you provide. Please pay special attention to the following sections and fill them out according to the revised instructions.

Description of Incident:*

Provide a detailed description of the incident or concern you addressed. For Formal Incident Reports and Employee Injury Reports, use clear and objective language, writing in the third person and avoiding "I". For example: RA Jane Smith responded to student John Brown's room. For Minor Reports, a first-person narrative is acceptable.

In this section, you will also include a brief overview of the following:

Immediate actions taken: Summarize the actions you took during the incident to manage the situation. A more detailed explanation will be provided in the "Detailed Actions Taken" section.
Communication: Mention any initial communication with involved parties, such as students, staff, or parents. This will be further elaborated in the "In-Depth Communication Details" section.
Follow-up actions: Briefly note any planned or recommended follow-up actions, which will be explained in detail in the "Comprehensive Follow-Up Strategies" section.

Additionally, describe the behaviors and activities that occurred, specifying any conduct violations identified. For formal and employee injury reports, use specific names and avoid pronouns. Direct quotes, including profanity or abusive language, are allowed. Remember to take photographs of any violations and upload them below.

Detailed Actions Taken:

If necessary, expand on the specific actions you took immediately following the incident. This section is for a more detailed account of what was done in response, such as managing the situation, ensuring safety, or providing first aid.

In-Depth Communication Details:

If necessary, provide a comprehensive summary of all communications related to the incident. Include detailed interactions with all parties involved, such as students, parents, guardians, or other staff members, after the incident occurred.

Comprehensive Follow-Up Strategies:

If necessary, detail any follow-up actions that are planned or recommended in response to the incident. This may include disciplinary measures, support recommendations for affected individuals, meeting suggestions with involved parties, or changes proposed to policies or environments to prevent similar incidents in the future. Provide a clear outline of the steps to be taken and the objectives they aim to achieve.

Were any of the following contacted in response to the incident? (Check all that apply)

Parents/Guardians

Emergency Contacts

Emergency Medical Services (EMS/EMT)

Police/Law Enforcement

Other (please specify)

Parent/Guardian Name:

First Last

Method of Contact with Parents/Guardians:

Please specify how the parents or guardians were contacted regarding the incident. Select the appropriate option from the list below (e.g., phone, email, or other).

Phone

Other

Parents/Guardians Contact Info:

When were parents/guardians contacted?

Parent/Guardian time of arrival:

Time that parents/guardians left:

Was the individual taken by their parents/guardians?

Yes

Where were they taken to by their parents/guardians?

Emergency Contact Name:

First Last

When were emergency contacts contacted?

Emergency contact time of arrival:

Time that emergency contacts left:

Was the individual taken by their emergency contacts?

Yes

Where was the individual taken to by their emergency contacts?

Name of EMS/EMT Responder or Person in Charge:

First Last

When were emergency medical services contacted?

EMS/EMT time of arrival:

EMS/EMT time of departure:

Was the individual taken by EMS/EMT?

Yes

Where was the individual taken to by EMS/EMT?

Name of Law Enforcement Responder or Person in Charge:

First Last

When were Police/Law Enforcement contacted?

Police/Law Enforcement time of arrival:

Police/Law Enforcement time of departure:

Was the individual taken by Police/Law Enforcement?

Yes

Where was the individual taken to by Police/Law Enforcement?

Name of "Other" Contact:

If you selected "Other" as a contact type, please specify the name of the individual or entity that was contacted in response to the incident.

When was the "Other" contact contacted?

"Other" contact time of arrival:

"Other" contact time of departure:

Was the individual taken by the "Other" contact?

Yes

Where was the individual taken by the "Other" contact?

Support Provided:

If applicable, detail any support or counseling provided to those affected by the incident.

Witness Accounts and Statements

Please provide detailed accounts and statements from any witnesses present during the incident. Include specific names and describe what each witness observed. If multiple witnesses provided statements, list them separately. Use direct quotes when applicable to accurately capture their perspectives.

Have all possible written witness accounts been collected?

Please confirm if all available written witness accounts have been gathered. If not, you'll be asked to provide a plan for collecting any outstanding statements. Note: This is only required for Health & Wellness (H&W) and Employee Injury Reports.

Yes

Upload Written Witness Accounts*

Since all written witness accounts have been collected, please upload a copy of these documents here. Ensure that all statements are legible and appropriately labeled.

Drop files here or

Max. file size: 80 MB.

What is the plan for collecting the remaining witness accounts?

If you have not yet gathered all written witness statements, please describe the plan for obtaining them. Include a timeline and any actions or communications you plan to take to ensure the remaining statements are collected. Note: This is only required for Health & Wellness (H&W) and Employee Injury Reports.

Additional Comments:

Upload Photos or Related Documents

Please upload any photos or other supporting documents related to the incident. This may include documentation such as ambulance reports, plumber documents, discharge papers, or other relevant materials.

Directions:

Photos: Ensure photos are taken of the incident area, any examples of documents, and discharge papers, if applicable.
Documents: Include any supporting documentation, such as reports from service providers (e.g., plumbers, EMTs), official discharge papers, or other relevant materials.

Drop files here or

Max. file size: 80 MB.

Signature of Reporter:*

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