Incident Report Form

This form is designated for reporting any incidents involving students of Mahad al Zahra – Houston. It is to be completed exclusively by a Janab or Learning Coach(s). The form and its responses are strictly confidential and must not be shared with any parent or guardian without prior authorization from the respective Idara and/or Masool.

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Incident Date and Time *

Date

Time

Please record the date and time of the incident itself, not the date and time when this form is being completed.

Student Full Name(s) *

If the incident involves multiple students, list the first student’s name normally. For all additional students, enter each name on a new line.

Student Program and Darajah *

Incident Location *

• Masjid
• Fakhri Makan
• Nuzul al Barakah
• Other

Detailed Description of Incident *

Clearly describe what happened, who else was involved, and whether any property and/or students were harmed during the incident.

Preliminary Action Taken *

State what preliminary action was taken immediately following the incident, and by whom.

and the notified

People who were notified of the incident: *

• Branch/Idara Masool
• Muhaffiz/Teacher
• Parent/Guardian
• Law Enforcement
• Hospital

Did the student(s) acknowledge this incident report? *

• Yes
• No

Attachments

Click or drag files to this area to upload. You can upload up to 10 files.

Attach pictures/videos of the incident, if any.

Certification *

First

Middle

Last

I certify that the information contained in this report is true and factual to the best of my knowledge. Sign with your full name.

Submit