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:  November 16, 2022