2015-16SCHOOL CRIME AND VIOLENCE INCIDENT REPORT

School Name______School Code ______

Date Incident Occurred ______Time Occurred______AM/PM

Name of Principal or Designee Reporting Incident to Law Enforcement: ______

Date Reported______Police Activity Number for This Report:______

Name of Person Sending This Report to Central Office ______Date Sent: ______

TYPE OF REPORTABLE OFFENSE (Check as many offenses as occurred during this incident) / TYPE WEAPON USED OR POSSESSED
1___Assault Resulting in Serious Injury / Firearms:
2___Assault Involving Use of a Weapon / 01___Handgun
3___Assault on School Personnel (not resulting in
serious injury) / 02___Rifle
4___ Death By Other Than Natural Causes / 03___Shotgun
Possession of Controlled Substances: / 08___Other – Specify:
5___Possession of Cocaine / Other Weapons:
6___Possession of Marijuana / 04___Pocket Knife (no matter the size)
7___Ritalin / 05___Boxcutter
17___Other / 06___Razor
87___Possession of Another’s Prescription Drug / 08___Other Weapon – Specify:
Use of Controlled Substances:
49___Use of Controlled Substances / LOCATION OF INCIDENT
50___Use of Narcotics / 01___Classroom
Selling of Controlled Substances: / 02___Hallway
54___Selling - Cocaine / 03___Cafeteria
55___Selling - Marijuana / 04___Office
56___Selling - Ritalin / 05___Restroom
57___Selling - Other / 06___Gym
Distribution of Controlled Substances: / 07___Stairway
88___Distribution of a Prescription Drug / 08___Other location in school building
8___Possession of a Weapon / 09___Parking lot
9___Possession of a Firearm or Powerful Explosive / 10___School grounds
10___Robbery With a Dangerous Weapon (Armed
Robbery) / 11___Off school grounds
12___Rape / 12___On School Bus
13___Sexual Offense / 13___Bus Stop
14___Sexual Assault (Not Involving Rape or Sexual
Offense
15___Adult Taking Indecent Liberties With a Minor / INCIDENT OCCURRED
16___Kidnapping / 01___During regular school activity
20___Possession of Alcoholic Beverage / 02___Weekend
48___Use of Alcoholic Beverage / 03___Summer School
43___Bomb Threat / 04___During non-school event
53___Burning of a School Building / 05___During extra-curricular school activity
06___Other:

CAMPUS WHERE INCIDENT OCCURS TAKES THE HIT FOR THE REPORTABLE

NOTE: NUMBERS LISTED ARE NCWISE CODES

OFFENDER(S):

Name/Student ID / Relation To School Code # / School
Consequence / Type of Offense (Code) (Refer to Pg. 1 for Code #) / Age / Sex
M/F / Race Code # / Grade K-12 / Excep. Student
Code #

CODE NUMBERS:

RELATION TO SCHOOL CODES: / EXCEPTIONILTIES CODES: / CONSEQUENCES CODES:
1 Student
3 Staff
5 Parent/Caregiver
6 Student from another
school
7 Non-student/Non-Staff
RACE CODES:
1 American Indian/Alaskan
Native
2 Asian/Pacific Islander
3 Hispanic
4 Black
5 White
6 Multi-racial / 02 Autistic
03 Deaf – Blind
04 Behaviorally-Emotionally
Disabled
06 Hearing Impaired
07 Specific Learning Disabled
08 Multi-handicapped
09 Orthopedically Impaired
10 Other Health Impaired
12 Speech-Language Impaired
14 Trainable Mentally Disabled
15 Visually Impaired
16 Traumatic Brain Injured
17 Developmentally Delayed
(ages 3-7 only) / 002 In-School Suspension
003 Out of School Suspension-10 days or Less
004 Out of School Suspension: 11-365 Days
005 Out of School Suspension: 365 Days
006 Expulsion
008 Alternative School
012 Report to Law Enforcement
021 Detention: During or After School
101 EC Only: Hearing held, no change in
placement
102 EC Only: Hearing held, change in
placement

VICTIM(S):

Name / Relation To School Code # / School
Consequence / Type of Offense (Code) (Refer to Pg. 1 for Code #) / Age / Sex
M/F / Race Code # / Grade K-12 / Excep. Student
Code #
  • Supporting documentation (attached)

___Student Discipline Referral Form

___Recommendation for Long Term Suspension Packet (if requested)

___Police/Sheriff ReportRevised06/17/15