MTA SAFETY AND SECURITY INCIDENT REPORT It is important for the Safety and Security of all members of the Association that this report be filled out and forwarded to the M.T.A. office as soon as possible after the incident occurs. In this way, we may follow up the District and/or the Board of Education to help correct those problems. A copy of this report will be forwarded to the Building Reps. Chairperson, Site Administrator, and Superintendent.

Date ___________________

Date Incident Occurred ______________Time Occurred ________

Location_________________________________________Person Reporting ______________________

Contact person ____________________________________Site ________Home Phone ( Reported To:

) _________

Site

_______ Time ______

Other (ie: police, fire, MUSD _______ Time______

Work Order # ________________________________________ Briefly describe incident (include persons involved and/or injuries): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________

Was there District Intervention and/or Investigation? Was the incident handled by the District to your satisfaction?

yes yes

no no

Do you have any suggestions which would have helped to avoid this incident?_______________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ (Place additional comments/information on reverse side)

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