Incident Report
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1COMMUNITY RELATIONS
10.21 AP.21
Incident Report
(Inappropriate Behavior toward Employees by Visitors)
Complete and submit this report to your immediate supervisor as soon as possible after the
incident.
D
I
_______________
ATE OF
NCIDENT
E
’
N
_____________________________________________________________
MPLOYEE
S
AME
P
/T
________________________________________________________________
OSITION
ITLE
W
? (Check)
HERE DID INCIDENT OCCUR
School site
School grounds
School-sponsored event
Central Office
Private residence
Public site (specify) ______________________________________________________________________
Other (specify) __________________________________________________________________________
D
/
: __________________________________________________
ESCRIBE
IDENTIFY INDIVIDUAL
_____________________________________________________________________________
D
’
. (Check the boxes that best categorize the actions and then
ESCRIBE INDIVIDUAL
S ACTIONS
describe those actions with specifics. Attach a separate sheet if necessary.)
Cursing/using obscenities
Disrupting or threatening to disrupt school or office operations
Acting in an unsafe manner (a manner that could have threatened the health and safety of others)
Making a verbal statement, a phone call, or a gesture indicating intent to harm you or to damage
school property
Sending a written statement indicating intent to harm you or to damage school property
Physically attacking you with the intent to harm you or to damage school property
Other (specify) ___________________________________________________________________
Specifics: ___________________________________________________________________
D
. (Check the boxes that best categorize your response and then
ESCRIBE YOUR RESPONSE
describe that response with specifics. Attach a separate sheet if necessary.)
Informed person(s) of provisions of and/or gave person(s) a copy of Policy 10.21
Hung up the phone on the person(s)
Asked person(s) to leave office/school/event
Called site administrator/designee for assistance
Called law enforcement officials
Other (specify) ___________________________________________________________________
Specifics: ___________________________________________________________________
_________________________________________________________
_________________
Employee’s Signature
Date
_________________________________________________________
_________________
Immediate Supervisor’s Signature
Date
D
R
S
/
: ______________________________
ATE
EPORT SUBMITTED TO
UPERINTENDENT
DESIGNEE
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