JICIA-E1 - Report of Dangerous Behavior by Student
MSAD #35
JICIA-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: ____________________________________________
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
Policy Form Reviewed: December 20, 2023