REPORTS OF DANGEROUS BEHAVIOR BY STUDENTS DIRECTED AGAINST SCHOOL STAFF
NEPN/NSBA Code: JLI-E
Note: This form must be completed by a person with first-hand knowledge of the dangerous behavior directed against school staff, or by a person assisting the person with first-hand knowledge of the behavior.
1. Name of Reporter: ____________________________________
2. Date of Report: __________
a. If the person filling out this form is assisting someone who has first-hand knowledge, please provide the name of the person with first-hand knowledge: _____________________________________________________________
b. Please check the appropriate line:
i. Staff member _________
ii. Student__________
iii. Other role (please specify):____________________________________
3. Information About the Incident
a. Name of school staff member(s) whom dangerous behavior was directed against:
_____________________________________________________________________
b. Date and time it occurred:
_________________________________________________________________
c. Location (be specific):
______________________________________________________
d. Brief description of any injuries or property damage:
________________________________________________________________
e. Other witnesses (if any), including names and positions:
________________________________________________________________
4. Contact information for follow-up (telephone and email):
_____________________________________________________________________
Adopted: February 8, 2024