Sample School Safety Incident Collection Form

Sample School Safety Incident Collection Form

Incident Portion

School Name: ______

School Number: ______

School district: ______

Incident Number?
______/ What was the date the incident occurred?
______
Where was the place of occurrence?
oOn school property/grounds (e.g., school building, athletic fields)
oBefore school hours
oDuring school hours
oAfter school hours
oAt an offsite alternative placement facility
oAt a school-sponsored event or at an event within the school’s
jurisdiction (e.g., athletic competition)
oOff school grounds at an activity under the jurisdiction of another school
(e.g., another school’s play)
oOff school grounds at an activity, function or event sponsored by the school
(e.g., visit to a museum)
oOn district provided public conveyance providing transportation to and from school
oOn district provided public conveyance providing transportation to a school sponsored activity, event, or function
oOff school grounds en route to or from school

Notes:

Offender(s) Information

Section I

Offender’s Status:
oAdult Visitor/Intruder
oDistrict Employee
oOther or Unknown
oParent
oStudent
oStudent from another school
oStudent with IEP
Offender’s Disability (if applicable):
oMental Retardation
oHearing Impairments
oSpeech/Language Impairments
oVisual Impairments
oEmotional Disturbance
oOrthopedic Impairments
oOther Health Impairments
oSpecific Learning Disabilities
oDeaf / Blindness
oMultiple Disabilities
oAutism
oTraumatic Brain Injury
oDevelopmental Delay
Local Offender #: ______/ PAsecureID: (10-digit number)
______
First Name (Not Mandatory):
______
Last Name (Not Mandatory):
______
Birthdate: ______
(month, day, and year)
Race/Ethnicity:
oAmerican Indian or Alaska Native
oAsian
oBlack or African American
oHispanic or Latino
oNative Hawaiian or Other Pacific Islander
oWhite / Grade: ______
When reporting online, PreK Half Day, PreK Full Day, K4 Half Day, K4 Full Day, K5 Half Day, K5 Full Day, Grades 1 through 12, Adult, Adult in Secondary Program, and Post Secondary Student options will be available.
Student Gender:
oMale
oFemale

Offender(s) Information

Section II

Misconduct Type: Mark all that apply.Numbers in parenthesis following selected misconduct types refer to violent criminal offenses as set forth in Title 18 of the Pennsylvania Consolidated Statutes (C.S.A.). For more information, click on the ? and/or reference number associated with the misconduct type (i.e.(§6306)).

Against a Person

oAssaults on Student(s)
oAggravated Assault (§2702)
oSimple Assault (§2701)
oAssaults on School Employee
oAggravated Assault (§2702)
oSimple Assault (§2701)
oRacial/Ethnic Intimidation (§5504)
oAll Other Forms of Harassment/Intimidation (§2709, 279.1, 2710)
oFighting
oMinor Altercation
oSexual Offenses
oRape (§3121)
oInvoluntary Sexual Deviate Intercourse
(§3123)
oStatutory Sexual Assault (§3122.1)
oSexual Assault (§3124.1)
oAggravated Indecent Assault (§3125)
oIndecent Assault (§3126)
oIndecent Exposure (§3127)
oOpen Lewdness (§5901)
oObscene and Other Sexual Materials
and Performances (§5903)
oSexual Harassment
oStalking (§2709.1)
oKidnapping/Interference with Custody of Child (§2901)
oUnlawful Restraint (§2902)
oThreatening School Official/Student
oReckless Endangering (§2705)
oRobbery (§3701, 3702)
oTheft
oAttempt (§901) to Commit or Commission of Any of the Following:
-- Homicide (§2501)
-- Murder (§2502)
-- Voluntary Manslaughter (§2503)
-- Involuntary Manslaughter (§2504)
oSuicide
oAttempted
oCommitted
oBullying /

Against Property

oBurglary (§3502)
oArson (§3301)
oVandalism (§3307)
oCriminal Trespass (§3503)
Against Society
oRioting (§5501)
oBomb Threats (§6161)
oTerroristic Threats (excl. Bomb Threats) (§2706)
oFailure of Disorderly Persons to Disperse Upon Official Order (§5502)
oDisorderly Conduct (§5503)

Illegal Possession of Weapon

Note: BB and/or pellet guns should be selected
under "Possession of Other Weapon" below.
oPossession of Firearm (§6110.1)
oHandgun
oRifle/Shotgun
oOther (Starter Gun, etc.)
oPossession of Knife
oPossession of Other Weapon (§5516)
oCutting Instrument (Razor, Box Cutter, etc.)
oExplosive (Bomb, Missile, etc.)
oBB/Pellet Gun
oOther Weapon:
______

Offender(s) Information

Section II (cont.)

Illegal Possession (Other)
oPossession or use of a Controlled Substance
oSale/Distribution of a Controlled Substance
oSale, Possession, Use, Transfer, or Under the Influence of Alcohol (§6010.3)
oPossession, Use, or Sale of Tobacco
(§6306, 6306.1, 6305) / Other Forms of Misconduct
o All other incidents as defined in local Student
Codes of Conduct:
Please explain: ______
______

Offender(s) Information

Section III

Local Law Enforcement (LLE) Notified:
o*Yes
oNo
*If Yes, what is the name of the contacted Local Law Enforcement (LLE) Office?
______/ Arrest:
Note: Arrest does not mean taking a person into custody. Removal of student, by police, does not constitute an arrest. There will be many situations in which law enforcement officials take a student into custody, but will not initiate criminal charges against the student.
An indication of pending arrest will not pass the EOY Release Scan. If an arrest has not been adjudicated by June 30th, then you must answer "No" to arrest. The report covers July 1st to June 30th of each year; if the status of the incident is not determined within those dates, then it must be reported as "No."
o*Yes
oNo
oPending
*If Yes is selected:
Offender charged with one of the following weapons possession offenses:
--Possession of Firearm by Minor (§6110.1)
--Possession of Weapon on School Property (§912)
--Possession of Prohibited Weapons (§908)
--Carrying Explosives on Conveyances
(§6161)
oYes
oNo
*Adjudication:
oAdjudicated Delinquent
oConvicted as Adult
oProbation
oCitation
oFined

Offender(s) Information

Section III (cont.)

School Sanction:
oNone
oDetention
oIn School Suspension
oOut of School Suspension
oExpulsion – Less Than One Calendar Year
oExpulsion – One Calendar Year
oExpulsion – More Than One Calendar Year
oOther: ______
Number of Days Suspended/Expelled: ______
(if applicable)
Received Educational Services During Expulsion?
oYes
oNo / Assigned to Alternative Education:
oYes
oNo
Was the student removed to an alternative education setting based on a State Hearing Officer's determination regarding likely injury? (if applicable)
oYes
oNo
Was physical injury involved as a result of this incident? (if applicable)
oYes
oNo
Did this injury require medical treatment?
(if applicable)
oYes
oNo
Did this removal involve serious bodily injury?
(if applicable)
oYes
oNo
Limited English Proficiency Status:
(if applicable)
oYes
oNo
Type of Parental Involvement:
oNone
oWritten Notification
oTelephone Conference
oSchool Conference
oFamily Counseling
oLaw Enforcement/Legal Involvement
oOther: ______/ Remedial Program:
oNone
oAlternative Education
oHomebound Instruction
oStudent Assistance Referral
oDrug/Alcohol Counseling
oGuidance Counseling
oPsychological Evaluation
oPeer Mediation/Conflict Resolution
oAnger Management
oOther: ______

Victim(s) Information

Victim’s Status:
oAdult Visitor/Intruder
oAgainst School/School Building
oDistrict Employee
oOther or Unknown
oParent
oStudent
oStudent from Another School
oStudent with IEP / Age: ______
When reporting online, Ages 4 through 24 will be available as well as Unknown.
Gender:
oMale
oFemale
oUnknown
School Grade: ______
When reporting online, PreK Half Day, PreK Full Day, K4 Half Day, K4 Full Day, K5 Half Day, K5 Full Day, Grades 1 through 12, Adult, Adult in Secondary Program, and Post Secondary Student, and Unknown optionswill be available. / Race/Ethnicity:
oAmerican Indian or Alaska Native
oAsian
oBlack or African American
oHispanic or Latino
oMulti-Racial
oNative Hawaiian or Other Pacific Islander
oOther Race
oUnknown
oWhite
Referred to SAP Program:
oYes
oNo / Required Medical Treatment:
o*Yes
oNo
*Reason(s) for medical treatment:
______
______