P.S. 16 OCCURRENCE FACT SHEET Type of Incident Accident Weapon/sharp object
Physical Aggression (fighting) Assault on staff member
Harassment
Sexual Harassment
Vandalism
Other _____________
Reported by: Name _______________________________ File No. ____________ Room _______ Class _______ Date of Incident _________ Time ______ Location ________ Activity _______________________ Name of Victim _________________________ ID or File No. ______________ Class ___________ Was parent notified? Yes ___ No___ If yes, date _______ time _____ Name of parent contacted ______________________________. Was person injured Yes____ No____ Body parts injured (be specific – i.e. right ankle)___________________________________________ Was first aid administered? ___ If so, Name of Nurse ______________________________________ Ambulance utilized
Staff Member Accompanying Student_______________ ___
Refused Medical Attention
LODI Requested (Staff)
NOTE: Please have victim write statement prior to leaving the building. Name of Suspect (Perpetrator) _____________________ ID. No.__________ Class ____________ Was parent notified? Yes ___ No___ If yes, date _______ time _____ Name of parent contacted _____________________________. Was person injured Yes____ No____ Body parts injured (be specific – i.e. right ankle)___________________________________________ Was first aid administered? ___ If so, Name of Nurse ______________________________________ NOTE: Please obtain statement from suspect if possible. Was the Police contacted? Yes ___ No ___ If yes, Names of Responding Officers _____________________________ Shield Numbers __________________________, Action Taken _____________________________________________ Names of Witnesses (please attach witness statements) Name _______________________ ID or File No. ________________________ Class __________ Name _______________________ ID or File No. ________________________ Class __________ Name _______________________ ID or File No. ________________________ Class __________ Was the Principal Notified of this incident? Yes __ No ___ If yes, what time/date __________________. Was the AP notified of this incident? Yes __ No ___ If yes, what time/date __________________. NOTE: Please complete this form and your Written Statement Form with a complete description of the incident. The name of each person making a statement must be entered on the top of their Statement Form and the form must be signed and dated. ALL FORMS MUST BE SUBMITTED WITHIN 24 HOURS OF THE INCIDENT . Supervisor Signature: ______________________________________________________Date:______________ Does this student need immediate removal from SCHOOL? Yes____No____ CLASSROOM Yes____No____