Athletics Student Incident Report
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Athletics Online Student Incident Referral
1.
Today's Date
mm/dd/yyyy
2.
Time of Incident
*
3.
Name of Referring Staff
*
4.
Staff Title
*
--Please Select--
Coach
Athletic Director
5.
Middle/High School Name
*
--Please Select--
*Middle Schools*
American Indian
Battle Creek
Capitol Hill
ESTEM
Farnsworth
Hazel Park
Highland Park
Humboldt
LWM/ Globar Arts Plus
Murray
Open World L
Parkway
Ramsey
Washington
*High Schools*
Central H.S
Como Park H.S
Harding H.S
Highland Park H.S
Humboldt H.S
6.
Student's Name
*
7.
Grade
*
--Please Select--
6th
7th
8th
9th
10th
11th
12th
8.
Incident Location
*
Incident Location
*
Classroom
Bathroom
Bus
Cafeteria
Gymnasium
Hallway
Library
Playground
Field
Other, please specify
9.
Names of Possible Witnesses
List Them
10.
Names of Other Individuals Involved
List Them
11.
Behavior Reported/Observed
*
--Please Select--
Abusive/inappropriate language, continual.
Bullying/hazing/cyber bullying.
Damage/vandalism to school property
Defiance/disrespect/non-compliance, continual
Discrimination: (racial/religious/gender/sexual)
Disruptive behavior, continual
Fighting
Harassment: (racial/religious/gender/sexual)
Leaving school grounds/area
Physical aggression to staff
Physical contact (bodily harm)
Stealing/theft, continual (serious case) > $ 5.00
Threatening
Skipping class
Possession/use of: (alcohol/drug/pyrotechnics)
Unauthorized use of district technology
Unsafe behavior from/to school
Weapons: possession/use
12.
Please make sure to notify your AD and School Admins right away
Has the AD Being Notified of This Incident?
*
Please make sure to notify your AD and School Admins right away
Has the AD Being Notified of This Incident?
*
Yes
No
13.
Perceived Motivation
*
Obtain peer attention
Obtain adult attention
Obtain items
Avoid peer(s)
Avoid adult(s)
Avoid tasks/activities
Unknown motivation
Other, please specify
14.
Staff Intervention Prior to This Referral
*
Verbal redirection
Non-verbal redirection
Re-taught expectations
Take a break
Buddy room
Student(s) conference
Social skills instruction
Fix-it plan/restitution
Loss of Privilege
IEP Case Manager/Counselor/Social Worker
Parent conference
Parent contacted
Other, please specify
15.
Staff’s Description of Incident
*
16.
SPPS Email Address
*