FORT ATKINSON SCHOOL DISTRICT

CODE BLUE REPORT

DATE________________________________          TIME                                                                   

SCHOOL_____________________________           LOCATION                                                        

NAME OF INDIVIDUAL                                                                                                                       

GRADE_____________________________             BIRTH DATE                                                     

ADDRESS                                                                                                                                               

PARENT(S)                                                                                                                                            

PARENT (S) CONTACTED WHEN ___________________     BY WHOM                                         

TEAM MEMEBERS IN ATTENDANCE                                                                                                 

SUMMARY OF INCIDENT                                                                                                                    

ACTION TAKEN                                                                                                                                    

TRANSPORT          YES or NO                                                      TO WHERE                                     

FOLLOW UP                                                                                                                                                  

REPORT COMPLETED BY                                                                                                                                                                                                                                         NAME

                                             SIGNATURE                                                                  DATE