Cleveland Metropolitan School District Form

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CLEVELAND METROPOLITAN SCHOOL DISTRICT

WITNESS STATEMENT

INCIDENT NUMBER

INVESTIGATOR

SCHOOL

__________________________________________________________________________

INCIDENT DATE ______/____/_____

INCIDENT TIME ___ a.m. p.m.

REPORT DATE ______/______/______

(circle one) STUDENT

EMPLOYEE

OTHER

(circle one) WITNESS SUSPECT VICTIM

RACE __________

SS# or STUDENT ID ________________________________ BIRTH DATE: _______/_______/_______

SEX (circle one)

LAST NAME _________________________________________________

FIRST____________________________________ M.I.______

ADDRESS_________________________________________________________ CITY___________________________ ZIP____________

PHONE __________________________________ PARENT/GUARDIAN_______________________________________________________

_____________________________________________________

STATEMENT

____________________________________________________________

(CONTINUE ON REVERSE SIDE IF MORE SPACE IS NEEDED)

I DECLARE THIS STATEMENT TO BE ACCURATE AND THAT IT HAS BEEN TAKEN SEPARATELY WITH NO OTHER WITNESSES PRESENT

WITNESS SIGNATURE: ______________________________________________________________

DATE ____/____/____

: _______________________________________________

DATE ____/____/_____

STATEMENT DICTATED TO AND WRITTEN BY

"The primary goal of the Cleveland Metropolitan School District is to become a premier school district in the United States of America"

"La meta primordial del Distrito Escolar Metropolitan de Cleveland es lograr ser un distrito escolar de primera clase en los Estados Unidos de America"