Report of Gang Related Activity
Today's Date *
MM
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DD
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YYYY
School/Neighborhood/Area/Business *
Person Reporting Incident/s: (may report anonymously)
Reporting person is: (can remain anonymous)
Clear selection
Contact Information: (can remain anonymous)
(ie., phone, email
Date/s Incident Occured
MM
/
DD
/
YYYY
Name of victim(s), student(s), or person(s) which gang members are committing acts against, *
Type of gang activity? *
Explain
Brief explanation of incident: *
Where did the gang activity happen? *
Example: hallway, playground, home, business
Did a physical injury result from this incident? *
Required
Medical attention required:
Are you aware if the victim missed any school as a result of this incident?
If yes, how many days was the student absent as a result of this incident?
Any other information that may be helpful in our investigation.
Example: Gang name, members gang name, affiliated color or clothing.
Note: The school district is not authorized to disclose to a target, private educational or personnel data regarding an alleged perpetrator who is a student or employee of the school district. School officials will notify the parent(s) of all students involved in a incident and the remedial action taken, to the extent permitted by law, based on a confirmed report.
OFFICE ONLY:
Person receiving report:__________________________________
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