Safety Concerns

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Safety Concerns

This form is available for any student, staff, and family/community member who has a safety concern related to a SASED student, staff member, or school/program.

I am a: *

What SASED program or service is involved in the concern? *

Assistive Technology

Audiology

Deaf & Hard of Hearing (DHH)

Itinerants (Hearing Itinerants, Occupational Therapy, Orientation & Mobility, Physical Therapy, Vision Itinerants)

Pathways - Southeast School

Project Search

SASED Medical Program

School Improvement/Instructional Support

SLE - Structured Learning Environment

Transition

Vision

Other:

Required

Event Description (include who, what, when, where and how do you know) *

Concern/Event Type:

Who are you concerned about?

Please provide as much of the following information about the person(s) of concern as possible:

Name of first person of concern:

Involvement of person 1:

Grade & Age of person 1

Race/Ethnicity of person 1

School/Location of person 1:

City/Town of person 1:

Description of Physical Appearance/Clothing of person 1:

Is there another person involved? *

Yes

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