Incident Report Form

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Incident Report Form

A person may notify the District of an Alleged Incident (“abuse” or “neglect”, as defined in the Texas Family Code) occurring in a Special Education Classroom or Other Special Education Setting where video/audio surveillance is in effect by completing an Incident Report form and providing it to the campus principal. The person making the Incident Report should be as specific as possible regarding the date, time, and location of the suspected abuse or neglect, should include any witnesses, and should describe the suspected abuse or neglect as clearly as possible. The Incident Report should be provided to the campus principal as soon as possible, and if at all possible within 48 hours after the reporter becomes aware of a suspected incident.

For your reference, “abuse” under the Texas Family Code §261.001(1) includes, but is not limited to: Mental or emotional injury causing observable and material impairment to a child’s development; Physical injury resulting in substantial harm or genuine threat of such harm; Sexual conduct or exploitation harmful to a child; Encouraging or failing to prevent such conduct by others.

“Neglect” under Texas Family Code §261.001(4) refers to acts or failures to act that demonstrate blatant disregard for a child’s health or safety, including: Leaving a child in a situation that poses immediate danger; Failing to provide necessary medical care, food, shelter, or protection; Failing to remove the child from harmful environments.

In order to make a request, complete the information below and submit this form. For more information, see EHBAF(LEGAL) and (LOCAL).

Requestor's Information

Name *

Phone Number *

Email Address *

Mailing Address *

I am a: *

Parent

Trustee

Staff Member

Alleged Incident Information

Student's Name *

Campus *

Hazel Ingram Elementary

Lucy Mae McDonald Elementary

Lee Longino

Ferris Junior High

Ferris High School

Specific classroom (room number and teacher’s/related service provider’s name) for which request is being made

Date incident occured *

YYYY

Describe the incident(s) as clearly as possible, including names of individuals involved *

To the best of my knowledge, this request meets the criteria in state law to require the District to conduct video and audio surveillance and recording upon request. *

Yes - By clicking 'Yes,' you authorize this as your virtual signature, indicating agreement

No - Based on my understanding, this request does not fulfill the legal requirements under state law for the District to perform video and audio surveillance upon request.

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This form was created inside of Ferris Independent School District.