Ministry of Education
APPENDIX: SAFE SCHOOLS INCIDENT REPORTING FORMS
CONFIDENTIAL
Report No:
________________
SAFE SCHOOLS INCIDENT REPORTING FORM – PART I
Name of School
1. Name of Student(s)
________________________________________________________________________________
Involved (if known)
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At a location in the school or on school property (please specify)
2. Location of Incident
_______________________________________________________________________________
(check one)
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At a school-related activity (please specify) ____________________________________________
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On a school bus (please specify route number) _________________________________________
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Other (please specify) _____________________________________________________________
3. Time of Incident
Date: _______________________
Time: _____________________
4. Type of Incident
Activities for which suspension must be considered under subsection 306(1) of the Education Act
(check all that apply)
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Uttering a threat to inflict serious bodily harm on another person
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Possessing alcohol or illegal drugs
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Being under the influence of alcohol
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Swearing at a teacher or at another person in a position of authority
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Committing an act of vandalism that causes extensive damage to school property at the student’s
school or to property located on the premises of the student’s school
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Bullying
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Any other activity for which a student may be suspended under board policy
[Note: Boards must specify on this form any other activities for which the principal may suspend
according to board policy.]
Activities for which expulsion must be considered under subsection 310(1) of the Education Act
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Possessing a weapon, including possessing a firearm
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Using a weapon to cause or to threaten bodily harm to another person
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Committing physical assault on another person that causes bodily harm requiring treatment by a
medical practitioner
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Committing sexual assault
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Trafficking in weapons or in illegal drugs
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Committing robbery
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Bullying (if the student has been previously suspended for engaging in bullying and the student’s
continuing presence in the school creates an unacceptable risk to the safety of another person)
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Any activity listed in subsection 306(1) that is motivated by bias, prejudice, or hate
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Giving alcohol to a minor
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Any other activity for which a student may be expelled under board policy
[Note: Boards must specify on this form any other activities for which the board may expel according
to board policy.]
Name:______________________________________________________________________
5. Report Submitted By:
Role in School Community: ___________________________________________________________________________
Signature:_________________________________________
Date: _________________
Contact Information: Location: _________________________________________
Telephone: _________________
6. FOR PRINCIPAL’S USE ONLY: Check if incident was a violent incident, as defined in Policy/Program Memorandum No. 120.
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Violent incident
Information is collected is under the authority Part XIII of the Education Act in accordance with the Municipal Freedom of Information and Protection of Privacy
Act, and shall be used for the purpose of student discipline. Questions about information collected on this form shall be directed to the school principal.