Reasonable Suspicion Report Form - Bacon Elementary School
1. Call the Nurse 2. Call the Administrator 3. Fill out This Form (Form SA 1 Confidential)
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* Required
Your Name (confidential)
*
Your answer
Name of Student (first and last):
*
Your answer
Briefly Describe the student's behavior:
*
Your answer
OBSERVE APPEARANCE: Please check all that apply
*
Smelling of Alcohol
Smelling of Marijuana
Glossy eyes
Bloodshot eyes
Dialated pupils
Constricted pupils
Dreamy, blank expression
Balancing problems
Sleeping in class
Trembling
Sudden outbursts
Crying
Mood swings
Slurred speech
Talkative
Incoherent
Inability to respond
Depressed mood
Greyish skin color
Flushed face
Other:
Required
POSSESSION OF: Please check all that apply
*
Vape pen or vaping paraphernalia
Alcohol
Nicotine
Marijuana
Inhalants
Perscription pills
Drug parephernalia
Steriods
Other:
Required
****A copy must be sent to the Doctor or hospital
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