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:
Date & time of the incident:
Name of student/person initiating the violent act:
Grade/age of the person initiating the violent act:
Location of the incident:
Select all that apply. Provide further description of behaviors checked on next item
Physical Violence (describe below)
Elopement (describe below)
Profanity (describe below)
Obscene gestures/behavior (describe below)
Urination/defecation (describe below)
Description of student/person behaviors:
Describe those items marked above.
Outcomes resulting from violent act:
Select all that apply. Provide further description on next item.
Injury sustained by staff (describe below)
Injury sustained by student(s) (describe below)
Damage to property (describe below)
Description of outcomes resulting from violent act:
Describe those items marked above
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