JGD-R5

Incident Code: ______________ CONFIDENTIAL

Form Ed317

Rev 1996

REPORT OF THEFT, DESTRUCTION, OR VIOLENCE

IN A SAFE SCHOOL ZONE TO LOCAL LAW ENFORCEMENT AGENCY

INSTRUCTIONS: This report shall be completed by a public or private school employee jointly with his/her supervisor immediately after awareness of an incident of a criminal nature. Not all information will be available at that time, but missing data shall be filled in within 48 hours by the principal. This report shall be filed with the local law enforcement agency by the principal within 48 hours of the incident.

School Name: ________________________________________ Principal’s Name: _______________________________

Address: _________________________________________________________ School Telephone: ___________________

INCIDENT DATE TIME OF INCIDENT LOCATION OF INCIDENT

____________________ _____________________________ ________________________________________

mo day year (specify AM or PM)

ALLEGED OFFENSES

p Drug/Alcohol Offense p Robbery, Burglary, Theft

p Firearm or other Weapon Offense p Arson

Type of Firearm: p Handgun p Rifle/Shotgun p Other p Criminal Mischief/Vandalism

p Homicide p Assault/Threat

p Sexual Offense

DESCRIPTION OF INCIDENT

(Include the names and addresses of any witnesses if appropriate)

SUSPECT VICTIM

Name _____________________________________ Name _____________________________________

Address _____________________________________ Address _____________________________________

_____________________________________ _____________________________________

Gender _________ Birthdate _____________ Gender _________ Birthdate _____________

mo day year mo day year

Grade _______

EMPLOYEE REPORTING INCIDENT DATE REPORT COMPLETED DATE REPORT FILED

by employee by Principal

Name _____________________________________ ____________________ ________________

mo day year mo day year

Adoption Date: January 14, 1997