Student

Grade

Referred by:

Team Student is on

If this is a repeated minor infraction please select from the following:

If contacted parent please put type the date, phone number and what the response was from the parent/guardian

If serious school violation, please select from the following:

If you selected OTHER in the serious school violation, fill in the details of OTHER:

Location of Incident

Staff Incident Report
Specify times, places, those involved, what happened before, during, and after the event and initial steps to address problem.

Suggested action by administrator

Additional Comments