Confidential Report of Physical Violence Acted Upon a Staff Member or Other Adult
To be completed by the victim and immediately submitted after informing the site Principal of the incident.
Name of person completing report: *
Your answer
School Site: *
Your answer
Date & time of the incident: *
MM
/
DD
/
YYYY
Time
:
Name of student/person initiating the violent act: *
Your answer
Grade/age of the person initiating the violent act: *
Your answer
Location of the incident:
Your answer
Student/person behaviors: *
Select all that apply. Provide further description of behaviors checked on next item
Required
Description of student/person behaviors: *
Describe those items marked above.
Your answer
Outcomes resulting from violent act: *
Select all that apply. Provide further description on next item.
Required
Description of outcomes resulting from violent act:
Describe those items marked above
Your answer
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