School Bus Student Incident Report
Incident Number:
Call OPT for Incident Number
(718) 392-8855
TO: FROM:
1
Recipient's Name
2
Recipient's Title
Principal Teacher
3
School's Name and/or Number
4
School Borough
5
Bus Company's Name
6
Bus Driver's Name
7
First Attendant's Name
8
Second Attendant's Name
INCIDENT DETAILS
9
Date of Incident
10
Time
AM PM
11
Location of Incident
12
Route Number
13 Please list each student involved in the incident, use an additional sheet if needed:
Student's Name
Student's
School Name
General Ed. (GE)
or
Special Ed. (SE)
Student ID Number
Student's Sex
GE SE
GE SE
GE SE
GE SE
GE SE
Chancellor’s Regulation A-412 requires that schools file an occurrence report for all student incidents within 24 hours.
Incidents include, but not limited to: bullying, student illness, student accident, student conflict, infractions of discipline code, etc.
14 Please describe the incident:
15
Full Name of First Witness to Incident (if available)
16
Full Name of Second Witness to Incident (if available)
17
Preparer's Signature
18
Today's Date
STOP - FOR SCHOOL USE ONLY
Date Entered into OORS Infraction Code OORS Control Number
