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 ; the approximate dates and the location : _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ________________________________________________________________________________________
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
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