Gang-Related Incident Reporting Form (Page 2 of 2) in pdf

_____________________________________________________________________________________________

________________________________________________________________________________

5. Where did the incident occur (choose all that apply)?

 On school property

 At a school-sponsored activity or event off school property

 On a school bus

 On the way to/from school*

Will be collected unless specifically excluded by local board policy

6. What did the alleged offender(s) say or do?

_____________________________________________________________________________________________

____________________________________________________________________________________________

(Attach a separate sheet if necessary)

7. Why did the activity occur? ___________________________________________________________

_____________________________________________________________________________________________

(Attach a separate sheet if necessary)

8. Did a physical injury result from this incident? Place an X next to one of the following:

 No

 Yes, but it did not require medical attention

 Yes, and it required medical attention

9. If there was a physical injury, do you think there will be permanent effects?  Yes  No

10. Was the student victim absent from school as a result of the incident?

 Yes  No

If yes, how many days was the student victim absent from school as a result of the incident? _________

11. Did a psychological injury result from this incident? Place an X next to one of the following:

 No

 Yes, but psychological services have not been sought

 Yes, and psychological services have

been sought

12. Is there any additional information you would like to provide (e.g. name of gang, clique, crew, or group, if

known)?

_____________________________________________________________________________________________

(Attach a separate sheet if necessary)

Signature: _________________________________________________________ Date: _________________

Gang-Related Incident Reporting Form Page 2