ER9 Incident Reporting Form

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This form is for students, parents or guardians of students enrolled in the school, and school employees to report any alleged challenging behavioral incidents. Challenging behavior is behavior that negatively impacts school climate or interferes, or is at risk with interfering, with the learning or safety of a student or the safety of a school employee. This form should also be used to report alleged bullying incidents, meaning: unwanted and aggressive behavior among children in grades kindergarten to twelve, inclusive, that involves a real or perceived power imbalance. We encourage parents who are comfortable to reach out directly to the school first regarding concerns, as this allows us to follow up promptly and directly.

Complete this form electronically, or go to your school climate specialist (principal, assistant principal, or other certified administrator) who will assist you with completing this form. All completed reports require a response from the school climate specialist, and every student, parent or guardian, and school employee who completed this form will receive a copy of the “Response Process(es) Notification Form” describing the action steps taken, within three (3) school business days after an assessment has been completed.

The school climate specialist will assess the facts of a challenging behavior incident and complete the "Response Process(es) Notification Form”. A confirmation of receipt of the Incident Reporting Form will be provided to the individual who completed this form within three (3) school business days, and the assessment will be finalized within a reasonable amount of time.

If this is an emergency, and you feel that you or someone else is in imminent danger, please call 911, or your municipal police department.

Name (optional)

Note: Anonymous complaints will be investigated. However, anonymous reports, depending on the information shared, but limit an investigation.

I am a: *

Student

Parent and/or Guardian

School Employee

Email address (optional):

Phone Number

Contact me by: *

Phone

Was this previously reported to any school employee prior to this report? *

Yes

If "Yes" to previous question, identify to whom, when and what was reported.

Where did the incident occur?

Check any of the boxes that apply.

On school property

At a school-sponsored activity

Electronic communication, internet or social media

On a school bus

On the way to/from school

Outside of school

Required

Approximate date of incident (if known):

YYYY

Please describe what happened: *

Of the following statement(s), check any that may describe what happened: *

Teasing, name-calling, intimidating, or threatening, in person or through electronic communication

Spreading rumors or gossip

Hitting, kicking, shoving, spitting, hair pulling, or throwing something or other acts of physical aggression

Making intimidating, and/or threatening gestures or remarks

Getting another person to do any of the behaviors listed above

Unwanted contact of a sexual nature (verbal, non-verbal, physical)

Required

Do you believe that the reported instance(s) of challenging behavior was/were in reference to a student’s perceived or actual age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical disability, mental disability, race, religious creed, sex, gender identity or expression, sexual orientation, and status as a veteran? If so, why?

If known, provide the name(s) of any witness(es) of the alleged incident *

Date form submitted *

YYYY

Select the School Climate Specialist who will be responding to this incident: *

Redding Elementary School

John Read Middle School, ER9 Coordinator

Staples Elementary School

Helen Keller Middle School

Joel Barlow High School

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This form was created inside of Easton Redding Region 9 Public Schools.

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