NEPN/NSBA Code: JLI-E
JLI-E DANGEROUS BEHAVIOR PREVENTION AND INTERVENTION INCIDENT REPORT
Dangerous Student Behavior refers to actions or conduct of a student that presents a risk of injury or harm to a student or others. Such behavior requires immediate attention and intervention to ensure the safety and well-being of all individuals involved.
If you believe you have been subjected to or observed dangerous student behavior, please complete this form and submit it to your building administrator as soon as practicable.
Note: This form must be completed by a person with first-hand knowledge of the dangerous behavior or by a person assisting the person with first-hand knowledge of the behavior.
Name of Person completing this form: ____________________________________
Phone: ____________________ Email: _________________________
Date of Report: _______________ Time:
Name of individual directly involved, if different from the person completing this form:___________________________________________________________________
Name(s) of student(s) or others involved: ____________________
Was anyone injured? (please circle one) Yes No
If someone was injured, please provide their name here:___________________________
Please briefly describe the dangerous behavior. Where did it occur? What occurred? If there were injuries, please describe the extent of the injuries. Who was present at the time of the incident? Please describe any property damage: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What interventions, if any, were implemented successfully and/or unsuccessfully at the time of the incident? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What steps were taken, if any, to support the individual against whom the dangerous behavior was directed?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Have prior Dangerous Behavior Incident Reports concerning individual(s) and student been filed with the administration? Yes No Unsure
Signature of person completing this form: ______________________
Date submitted to building administration: ______________________
Reviewed by: (Administrator)____________________________________________________
Date Received: ___________________________
Reviewed by (Assigned public school employee):________________________
Date received: ____________________
Adopted: February 8, 2024
Revised: February 13, 2025