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Student may pose a threat of :

Harm to self

Harm to Others

Damage to school property

Summary : Brief desciption the issue or your concern :

Date : When did the issue occurs? :

Did you personally witness the icident or behavior? :

Yes

No

Description : Describe what you observed. Exactly what was said or done by the student? :

Quote as much as possible, use quotation marks to identify direct quotes

Target or victim : If known, list the target or victims :

List each name, and wheather a student, teacher, parent, administrator or other

Witnesses: list other witnesses. :

List each name, includeing students grade.

Personal close to the sudent List student, staff, or toerhs who knows the student will. :

Example:Best friend, boyfriend/girlfriend, coach.