Violence, Vandalism, And Substance Abuse (Vv-Sa) Incident Report Form
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V
, V
,
S
A
(
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) I
R
F
IOLENCE
ANDALISM
AND
UBSTANCE
BUSE
VV
SA
NCIDENT
EPORT
ORM
INCIDENT INFORMATION
System-Assigned
2015-2016
Incident Number ____________
Local Incident Number
INCIDENT HEADER (Use one Incident Report Form for all offenders and victims of any one incident.)
(Optional) _________________
School Name:_________________________________________________
Location: ______Cafeteria
______Classroom
______Corridor
______Other Inside School
______School Entrance
______Building Exterior
______Other Outside
_____Bus
______Locker Room
______Off-site School-Sponsored Function
______Other School Grounds
______Off School Grounds (HIB only)
______Off-site Program*
Date of Incident:_______________
Time of Incident:_______________
______Bias-Related
______Gang-Related
Police Notification: ____None
____Police Notified, Complaint Filed
____Police Notified, No Complaint Filed
Contact Name:________________________________________________
Contact Phone #_____________________________
INCIDENT TYPE
(There can be multiple offense categories in one incident report)
SUBSTANCE OFFENSE
VANDALISM RELATED
VIOLENCE
____ Possession
____ Sale/Distribution
____ Arson
____ Theft (>=$10)
____ Use confirmed
____ Assault
____ Criminal Threat
____ Bomb Threat
____ Trespassing
SUBSTANCE TYPE
____ Burglary
____ Fire Alarm Offense
____ Extortion
____ Damage to Property
____ Fireworks Offense
____ Fight
____ Alcohol
____ Threat
____ Fake Bomb
____ Marijuana
____ Kidnapping
_____ Cost Incurred by LEA? (only check if yes)
____ Amphetamines
____ Robbery
____ Designer/Synthetic Drugs (e.g., Party Drugs, Club Drugs,
____ Sex Offense
____ HARASSMENT, INTIMIDATION OR BULLYING
Bath Salts, Synthetic Marijuana, China White, Synthetic
(Affirmed (i.e. found to be HIB) by the Board of Education)
Heroin (MPTP), Ecstasy (MDMA), GHB, Rohypnol K2, Spice,
Cloud Nine (MDPV))
WEAPONS
Check either Possession or Used in Offense
____ Cocaine/Crack
____ Hallucinogens (e.g., THC, LSD, Jimson Weed, Angel Dust
____ Sale/Distribution of Weapon
Possession
Used in Offense
(PCP) Psilocybin (Mushrooms), DMT, Ketamine,
_____
_____ Handgun
Mescaline (Peyote))
_____
_____ Rifle
BOMB OFFENSE
____ Narcotics (e.g., Morphine, Heroin, Hydrocodon, Oxycodone,
_____
_____ Air Gun, Pellet Gun, BB Gun
Codeine, Vicodin, Methadone)
_____
_____ Imitation Firearm
_____ Bomb – exploded
____ Depressants (e.g., Barbiturates, Valium, Xanax, Tranquilizers)
_____
_____ Knife, Blade, Razor, Scissors,
_____ Bomb – unexploded
Box Cutter
____ Anabolic Steroids
*
_____
_____ Pin, Sharp Pen/Pencil
____ Unauthorized Prescription Drugs
Select “off-site program” when a program that is part of a
_____
_____ Chain, Club, Brass knuckles
school in which the student is enrolled but that operates at
____ Unauthorized Over the Counter Drugs
_____
_____ Spray
another site and has NOT been assigned a school code by the
____ Inhalants
Department of Education. You may indicate the off-site
_____
_____ Other
____ Drug Paraphernalia
program name and address in the “Incident Description” field.
Incident Description: _____________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
___________________________
________________________
____________
___________________________
____________
Signature 1
Title
Date
Signature 2 (principal)
Date
Report Form Set: Incident, Offender, Victim and HIB pages
E00-00317
Revised September 2014
Revised 8/15
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