SIGNALEMENT DES INCIDENTS

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RAPPORT D’INCIDENT

AUTEUR DU RAPPORT

NOM : 
PRENOM :
FONCTION :
DATE :

ELEVE

NOM :
Prénom :
Classe :

Objet du rapport
□Discipline/comportement                                      □Travail                                 □Information

Conditions particulières dans lesquelles l’incident s’est déroulé
(NOMS, Positions, témoins,…)

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Souhaitez-vous une intervention ? De quelle sorte ?
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PARTIE RESERVEE AU CHEF D’ETABLISSEMENT
Suite donnée au rapport
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Signature :                                                                                         Date: ----/----/----

     
     

 

 

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