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