SCHOOL THREAT ASSESSMENT TEAM

REPORT OF CONCERN FORM

Today’s Date**

Answer Required

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

Answer Required

Type of concern: (Select all that apply)*

Answer Required

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

Time (If Applicable)

Answer Required

Do you feel YOU are in immediate danger?**

Answer Required

Yes

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

Answer Required

Yes

Attachment of Video or Photographic Evidence

Answer Required

Choose a file or drag it here.

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

Answer Required

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