Student Incident Report Page 2
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4Student Incident Report
Attachment A: Student Screening Form
Student’s Name:
Date:
General medical information will be in the student’s school medical file. This screening form is to be completed
by the staff making the initial contact with a student who appears intoxicated.
Answer the following questions and record breathalyzer results:
1. Does the student appear to be under the influence of alcohol or drugs?
[
] Yes
[
] No
2. Is the student carrying any medications?
[
] Yes
[
] No
3. Did you ask the student if he or she was on any medications?
[
] Yes
[
] No
4. Does the student have any signs of physical injury?
[
] Yes
[
] No
5. Is the student out of control or physically violent to self and/or others?
[
] Yes
[
] No
6. Breathalyzer results:
If you detect or observe any other health problems, please explain:
Check results of the student’s screening assessment:
1. [
]
Student was transported to the emergency room
2. [
]
Student was accompanied by a staff member to sick bay, transition dorm, or dorm of origin
3. [
]
Other, please explain:
4. [
]
Referral from (Attachment B) completed and forwarded
Staff’s Name (print)
Date and Time
Staff’s Signature
Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones
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