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Student Incident Report

Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones

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Part I: Biographical Information

School’s Name: Incident’s Date and Time:

Student’s Name: Age: Grade:

Incident’s Location: [ ] School [ ] Dorm [ ] Other (specify):

School Category or Offense:

If the incident is alcohol or drug related, complete Attachments A, B, and C.

Name of Other Involved Name of Other Involved Name of Other Involved Name of Other Involved

Part II: Incident's Description (e.g., what happened and who was involved?)—attach additional sheets as needed:

Part III: Action Taken:

Part IV: People who were notified of the incident:

[ ] Parent/Guardian: Date and Time:

[ ] Law Enforcement: Date and Time:

[ ] Hospital/EMT: Date and Time:

[ ] Education Line Office: Date and Time:

Did student acknowledge the report? [ ] No [ ] Yes, when:

Part V: Certification

I certify that the information contained in this report is true and correct to the best of my knowledge.

Signature Date Telephone Number

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Student Incident Report

Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones

2 of 4

Attachment A: Student Screening Form

Student’s Name: Date:

General medical information will be in the student’s school medical file. This screening form is to be completed

by the staff making the initial contact with a student who appears intoxicated.

Answer the following questions and record breathalyzer results:

1. Does the student appear to be under the influence of alcohol or drugs? [ ] Yes [ ] No

2. Is the student carrying any medications? [ ] Yes [ ] No

3. Did you ask the student if he or she was on any medications? [ ] Yes [ ] No

4. Does the student have any signs of physical injury? [ ] Yes [ ] No

5. Is the student out of control or physically violent to self and/or others? [ ] Yes [ ] No

6. Breathalyzer results:

If you detect or observe any other health problems, please explain:

Check results of the student’s screening assessment:

1. [ ] Student was transported to the emergency room

2. [ ] Student was accompanied by a staff member to sick bay, transition dorm, or dorm of origin

3. [ ] Other, please explain:

4. [ ] Referral from (Attachment B) completed and forwarded

Staff’s Name (print) Date and Time

Staff’s Signature

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Student Incident Report

Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones

3 of 4

Attachment B: Referral Checklist

Student’s Name: Date:

1. [ ] Student has possession of alcohol or drugs

2. [ ] Student displays visible signs of alcohol of drug use

3. [ ] Student is sleeping off alcohol or drugs

4. [ ] Student is self-referred for alcohol or drugs

Describe in a brief written narrative what symptoms the student demonstrated or what activities led to this

student’s referral:

Please list other students who were involved in this activity:

Staff’s Printed Name or Student Making the Referral

Staff’s Signature or Student Making the Referral Date

Note: The student assistance team will receive a copy of the completed and signed referral checklist the

next day.

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signature

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Student Incident Report

Distribution: FAX a copy to the designated School Safety Specialist—Walter Goodwin, Eric North, or Desmond Jones

4 of 4

Attachment C: Observation Form

Student’s Name: Date:

If the student is intoxicated, document that the student is checked every fifteen minutes. If the student is not

intoxicated, record observations every thirty minutes. Use additional forms as needed.

Upon initial entry to the sick bay/transition dorm or dorm of origin, staff will record student observations in

Table 1.

Table 1: Observation Entries

Time

Observation

Initials

Time

Observation

Initials

Staff on Duty Time in Time out

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Fillable Student Incident Report

Fill Online, Printable, Fillable, Blank Student Incident Report Form

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