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
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