Version 1/6/2011

Attachments:

_______ yes

______ no

Moultonborough School District, SAU #45

Version 1/6/2011

Safety Incident Report PART 1: Incident Report: Person filing report:

Date:

All safety incident reports should be filed in writing with the Building Administrator within 24 hours of the incident. The Building Administrator will immediately relay report to the Superintendent.

Date of incident:

Time of incident:

Description of incident (include names of persons involved, witnesses (if any), location, quotes, and any other factually relevant information): ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ Attachments:

_______ yes

______ no

Version 1/6/2011

Attachments:

_______ yes

______ no

Version 1/6/2011

Attachments:

_______ yes

______ no

Moultonborough School District, SAU #45

Version 1/6/2011

Part II: Follow-Up Received by administrator:

Date/Time:

Summary of administrative investigation: ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________

Finding: ______ Harassment ______ Restraint ______ Bullying (JICK)

______ Sexual harassment (JBAA) ______ Report to external agency (DCYF, JPPO, MPD) ______ Other (Please describe): _____________________________

Action(s) taken: Contacts: Name ___________________________ ___________________________ ___________________________ ___________________________

Relation ______________________________ ______________________________ ______________________________ ______________________________

Date/Time Contacted: ____________________ ____________________ ____________________ ____________________

Refer to child study team?

_____yes

_____no

Date: _____________________

Refer to Safe Schools team?

_____ yes

_____ no

Date: _____________________

Staff notified? MCS

_____ yes

_____ no

Date: _____________________

_____ yes

_____ no

Date: _____________________

MA

Follow-up with referring person? Submitted to SAU by:

Date: _____________________

Written report must be submitted to Superintendent within 10 working days of incident report. Attachments:

_______ yes

______ no