Student Incident Report

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Student Incident Report
Part I: Biographical Information
School’s Name:
Incident’s Date and Time:
Student’s Name:
Age:
Grade:
Incident’s Location: [
] School [
] Dorm
[
] Other (specify):
School Category or Offense:
If the incident is alcohol or drug related, complete Attachments A, B, and C.
Name of Other Involved
Name of Other Involved
Name of Other Involved
Name of Other Involved
Part II: Incident's Description (e.g., what happened and who was involved?)—attach additional sheets as needed:
Part III: Action Taken:
Part IV: People who were notified of the incident:
[
] Parent/Guardian:
Date and Time:
[
] Law Enforcement:
Date and Time:
[
] Hospital/EMT:
Date and Time:
[
] Education Line Office:
Date and Time:
Did student acknowledge the report?
[
] No
[
] Yes, when:
Part V: Certification
I certify that the information contained in this report is true and correct to the best of my knowledge.
Signature
Date
Telephone Number
Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones
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