Critical Incident Or Death Reporting Form - Us Department Of The Interior
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1Bureau of Indian Education
Critical Incident or Death Reporting Form
The Critical Incident or Death Reporting Form documents a critical incident or death occurring at a school.
Users will complete and fax the form immediately to: the Bureau of Indian Education (BIE) Director or official
designee at (202) 208-3312, the respective Associate Deputy Director or official designee, the Chief of Staff
at (202) 208-3312, the Suspected Child Abuse/Neglect (SCAN) Program Specialist at (505) 563-5292, and the
respective Education Line Office.
School Name:
Date:
Student Name:
Grade:
Tribe:
Age:
Incident Location: [
] School
[
] Dorm
[
] Other (specify):
Incident Description (e.g., what happened, who was involved?)—attach additional sheets as needed:
Indicate persons who were notified of the incident (if applicable):
[
] Parent/Guardian:
Date/Time:
[
] Law Enforcement:
Date/Time:
[
] Hospital/EMT:
Date/Time:
[
] Education Line Office:
Date/Time:
Certification:
I certify that the information contained in this report is true and correct to the best of my knowledge.
Signature
Date
Telephone Number
Re-issued: 7/23/2013
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