Wufoo

Safety/Discipline Report Form

• Name * First Last
• Personal Email *

  Non-DOE email only

• Phone Number * ### - ### - ####
• File or EIS# *
• School or Worksite *
• District *
• Borough *
• Date of incident MM / DD / YYYY
• Time of incident HH : MM : SS AM/PM
• Did you report this incident to the school's administration?

  Yes No
• Have you notified your UFT Chapter Leader?

  Yes No
• Chapter Leader First Last
• Did you file a DOE occurrence report?

  Yes No
• Type of safety/discipline concern: *
• Were you injured as a result of this incident?

  Yes No
• Provide a brief summary of the incident *
  Maximum Allowed: 1000 characters.    Currently Used: 0 characters.
• Do Not Fill This Out