SCHOOL THREAT ASSESSMENT TEAM

REPORT OF CONCERN FORM

Today’s Date**

Answer required for "Today’s Date*"

Full Name of Student (s) of Concern and Grade Level (s):*

Answer required for "Full Name of Student (s) of Concern and Grade Level (s):"

Type of concern: (Select all that apply)*

Answer required for "Type of concern: (Select all that apply)"

Bullying, Hazing, Intimidation

Suicide and/or Self-Harm, Depression/Isolation

Violence Toward Others

Violence at Home

Explicit Content Online

Vandalism, Weapon

Substance Abuse

Inappropriate Behavior Online

Other:

Location of Incident**

Answer required for "Location of Incident*"

Time (If Applicable)

Answer required for "Time (If Applicable)"

Do you feel YOU are in immediate danger?**

Answer required for "Do you feel YOU are in immediate danger?*"

Yes

Do you feel the Student Body or School Building is in immediate danger?**

Answer required for "Do you feel the Student Body or School Building is in immediate danger?*"

Yes

Attachment of Video or Photographic Evidence

Answer required for "Attachment of Video or Photographic Evidence"

Choose a file or drag it here.

Please describe the Concerning Behavior in as much detail as possible.**

Answer required for "Please describe the Concerning Behavior in as much detail as possible.*"

Should the Behavioral Threat Assessment & Management Teams (BTAM) have reason to believe that the Report of Concern was wrongfully or falsely submitted, the Roselle Park School district reserves the right to utilize disciplinary action.

Please fix the highlighted areas below before submitting.

Student of Concern

SCHOOL THREAT ASSESSMENT TEAM

REPORT OF CONCERN FORM