Type of Report (Original, Supplemental, Follow-up) INCIDENT DATE/TIME OF INCIDENT: DATE/TIME OF REPORT: INCIDENT ADDRESS - - NAME OF SCHOOL/BUILDING: AREA: REPORTING OFFICER/ BADGE # - TYPE OF INCIDENT WEAPON USED BY SECURITY WEAPON USED BY OTHERS (OFFENSE): Yes No TYPE: Yes No TYPE: Gun -Asp/Baton - Other Gun Taser - Other –Mace –Taser –Mace – Assault 1st - Assault 2nd- Assault INCIDENT LOCATION: INJURIES: Yes No 3rd Burglary - Drugs/Alcohol – Surface (Tile, concrete, asphalt, UUW Gun UUW Knife - Sex Offense carpeting), Stairwell Hallway Class Room – – – Stealing Robbery 1st Robbery – – Conditions (moisture, holes in Cafeteria School Yard Rest Room - – – 2nd Missing Peace Disturbance - – surface, etc.), If applicable School Bus – Trespassing Weather If applicable Other VICTIM 1: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student 2: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Staff 3: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Staff WITNESS Witness 1: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Witness 2: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Witness 3: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: #2 Student Staff MEDICAL TREATMENT Medical Log, if treated by School Nurse –Attach –Clinical Treatment at scene by School nurse Treatment at scene by EMS Treated by Personal Physician Transported to Hospital Refused Medical Attention Hospital Name: SUSPECT/OFFENDER Suspect 1: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Staff Suspect 2: D.O.B. Race: Sex: Address: #1 SSN# SN# Parent/Contact: Phone #2 Student Staff
Type of Report (Original, Supplemental, Follow-up) INCIDENT DATE/TIME OF INCIDENT: - DATE/TIME OF REPORT: - INCIDENT ADDRESS NAME OF SCHOOL/BUILDING: AREA: REPORTING OFFICER/ BADGE # - TYPE OF INCIDENT (OFFENSE): WEAPON USED BY SECURITY Yes No TYPE: Gun -Asp/Baton –Mace –Taser - Other WEAPON USED BY OTHERS Yes No TYPE: Gun –Mace – Taser - Other Assault 1st - Assault 2nd- Assault 3rd Burglary - Drugs/Alcohol – UUW Gun UUW Knife - Sex Offense – Stealing Robbery 1st – Robbery 2nd – Missing Peace Disturbance - Trespassing INCIDENT LOCATION: Stairwell – Hallway – Class Room – Cafeteria – School Yard – Rest Room - School Bus – Other INJURIES: Yes No Surface (Tile, concrete, asphalt, carpeting), Conditions (moisture, holes in surface, etc.), If applicable Weather If applicable VICTIM 1: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student 2: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Staff 3: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Staff WITNESS Witness 1: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Witness 2: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Witness 3: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: #2 Student Staff MEDICAL TREATMENT –Attach Medical –Clinical Log, if treated by School Nurse Treatment at scene by School nurse Treatment at scene by EMS Treated by Personal Physician Transported to Hospital Refused Medical Attention Hospital Name: SUSPECT/OFFENDER Suspect 1: D.O.B. Race: Sex: Address: Phone #1 SSN# SN# Parent/Contact: Phone #2 Student Staff Suspect 2: D.O.B. Race: Sex: Address: #1 SSN# SN# Parent/Contact: Phone #2 Student Staff
SLPS_Incident_Report_Form_040615.docx