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Upward Bound Incident Report Form
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Name of Staff Completing Report
First
Last
Date of Incident
MM
/
DD
/
YYYY
Name of Student(s) Involved
Incident's Description
Please describe what happened in your own words. Include as many details as possible
to give a clear, accurate account of the events.
Action Taken
People notified of the incident
UB Staff
Parent/Guardian
Medical Personnel
Other
