HTML Preview Behavioral Emergency Incident Report Form page number 1.
White – Site Canary – Teacher Pink – Parent
MT. DIABLO UNIFIED SCHOOL DISTRICT
SPECIAL EDUCATION
BEHAVIORAL INCIDENT
EMERGENCY REPORT
ROUTING SLIP
1936 Carlotta Drive, Concord, CA 94519
Phone (925) 682-8000 or TDD 685-1962
FAX (925) 687-3139
Community Advisory Committee (CAC)
Parent Resource Network (925) 687-2129
Provide name of person to whom the incident was reported, date and initial of person reporting.
(Parent/care provider must be notified within one (1) school day.)
Who Must Be Notified Name Date Initials
Administrator
Parents
Others Who May be Notified
Program Specialist
Doctor/Hospital
Police
CFS(Child and Family Services)
Director of Special Education
Mental Health Agency
Behaviorist
Copies of this Report Must be Sent to:
Initials
Staff File*
Cumulative*
Incident Report File*
Risk Management (if staff or student injury)
CFS
Director of Special Education*
Mental Health Agency*
Parent
Rev. 09/04 Page 1 of 6
Student: ______________________________________________ Student No.: ________________________
Date of Incident: ________________________ Day: M T W Th F Incident Start Time: ____________