Indicate if there are witnesses who can provide more information regarding your report. If the witnesses
are not school district staff or students, please provide contact information.
Name Address Telephone Number
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________
Have there been previous incidents (circle one)? Yes No
If “yes”, please describe the behavior of concern, or the violence that occurred; include the approximate
date(s) and the location(s):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________
Were these incidents reported to school employees (circle one) Yes No
If “Yes”, to whom was it reported and when?
______________________________________________________________________________
Was the report verbal or written?
______________________________________________________________________________
Proposed Solution:
Indicate your opinion on how this problem might be resolved in the school setting. Be as specific as
possible.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_________________________________________________________
I certify that the above information and events are accurately depicted to the best of my knowledge.
______________________________________________________________________________
Signature of Reporter Date Submitted Received By Date Received
Adopted: January 24, 2012
Revised: March 27, 2012
Revised: May 12, 2015
56