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
Adopted: January 24, 2012
Revised: March 27, 2012
Revised: May 12, 2015
27
Received By
Date Received