Student Incident Report Page 3
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4Student Incident Report
Attachment B: Referral Checklist
Student’s Name:
Date:
1. [
]
Student has possession of alcohol or drugs
2. [
]
Student displays visible signs of alcohol of drug use
3. [
]
Student is sleeping off alcohol or drugs
4. [
]
Student is self-referred for alcohol or drugs
Describe in a brief written narrative what symptoms the student demonstrated or what activities led to this
student’s referral:
Please list other students who were involved in this activity:
Staff’s Printed Name or Student Making the Referral
Staff’s Signature or Student Making the Referral
Date
The student assistance team will receive a copy of the completed and signed referral checklist the
Note:
next day.
Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones
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