JIC-E1 - Report of Dangerous Behavior by Student

JIC-E1 - Report of Dangerous Behavior by Student

1.          Name of Reporter: _________________________________  Date of Report: __________

Please note: This form must be completed by a person with first-hand knowledge of the dangerous behavior, or by a person assisting the person with first-hand knowledge of the dangerous behavior.

a.            Please check the appropriate line:  _______Staff member  ___________Student

__________ Other role (please specify):_________________________________

2.          If the person filling out this form is assisting someone who has first-hand knowledge, please provide the name of the person with first-hand knowledge:

________________________________________________________________

a. Please check the appropriate line:  _______Staff member   ___________Student

__________ Other role (please specify):_________________________________

3.          Information About the Incident

a. Date and time it occurred: ____________________________________________

 MSAD #35

b. Location (be specific): ________________________________________________

c.  Brief description of dangerous behavior by student (included who was directly subjected to the behavior, any injuries or property damage): ___________________________________

_____________________________________________________________________________

______________________________________________________________________________

 _____________________________________________________________________________

d. Other witnesses (if any), including names and positions: ____________________________

_____________________________________________________________________________

4.          Contact information for follow-up (telephone and email): ______________________________

_____________________________________________________________________________

PLEASE FOLD THIS REPORT, STAPLE OR TAPE IT CLOSED FOR SECURITY, AND DELIVER TO THE BUILDING PRINCIPAL.  YOU WILL BE CONTACTED AFTER THE REPORT HAS BEEN ASSESSED.  THANK YOU.

For administrative use

Date the report was received in principal’s office: ___________________________________________

Policy Form Adopted: