VIOLENT AND DISRUPTIVE INCIDENT REPORT (VADIR) FORM

Make additional copies of this form as needed. Do not send copies of this form to SED. Annual summary results for all reportable incidents occurring during the school year, between July 1 and June 30, should be reported on the SED Electronic VADIR System.

SCHOOL NAME______________________________________________

DESCRIPTION OF INCIDENT:

1. CATEGORY OF INCIDENT - If the incident involves multiple categories, one category choice is determined by the building official(s)/police handling the matter. The bold characters to the right of each item indicate the sections for annual reporting on the Summary of Violent and Disruptive Incidents Report where tallies of the corresponding incidents will be entered. (Check (Ö ) all columns that apply.) Category definitions are summarized in this document and detailed in the Glossary of Terms.

	With Weapon	Without Weapon	Involving Alcohol or Drugs	On School Transpor-tation
1. Homicide (1a): conduct that results in the death of another person.
2. Forcible Sexual Offense (2.1a): involving forcible compulsion.
2.2 Other Sexual Offense (2.2a): involving inappropriate sexual contact (no forcible compulsion.)
3. Robbery (3a): forcible stealing of property from a person by threatening the immediate use of physical force.
4. Assault with Serious Physical Injury (4a): intentionally or recklessly causing physical injury which creates substantial risk of death or serious or protracted disfigurement or protracted impairment of health or protracted loss or impairment of the function of any bodily organ.
5. Arson (5a): deliberately starting a fire with intent to damage or destroy property.
6. Kidnapping (6a): to abduct a person or restrain a person with intent to prevent his or her liberation.
7. Assault with Physical Injury (7a): intentional or reckless act causing impairment of physical condition or substantial pain. (In violation of the school district code of conduct).
8. Reckless Endangerment (8a): subjecting individuals to danger by recklessly engaging in conduct that creates a grave risk of death or serious injury but no actual physical injury.
9. Minor Altercations (Assaults) (9a): involving physical contact and no physical injury.
10. Intimidation, Harassment, Menacing or Bullying (10a): no physical contact - intentionally placing another person in fear of imminent physical injury. Incidents that do not result in a consequence (j-o) are reported in Item 2 page 3.
11. Burglary (11a): entering or remaining unlawfully on school property with intent to commit a crime.
12. Criminal Mischief (12a): Intentional or reckless damaging of school property or the property of another person, including but not limited to vandalism and the defacing of property with graffiti.
	With Weapon	Without Weapon	Involving Alcohol or Drugs	On School Transpor-tation
13. Larceny, or Other Theft Offense (13a): unlawful taking and carrying away of personal property with intent to deprive the rightful owner of property. Permanently or unlawfully withholding property from another.
14. Bomb Threat (14a): a telephoned, written or electronic message that a bomb, explosive or chemical or biological weapon has been or will be place on school property.
15. False Alarm (15a): falsely activating a fire alarm or other disaster alarm.
16. Riot (16a): four or more persons simultaneously engaging in tumultuous and violent conduct and thereby intentionally or recklessly causing or creating a grave risk of physical injury or substantial property damage or causing public alarm.
17. Weapons Possession Only (17a)
18. Use, Possession, or Sale of Drugs Only (18a)
19. Use, Possession, or Sale of Alcohol Only (19a)
20. Other Disruptive Incidents (20a): incidents involving disruption to the educational process serious enough to lead to consequence listed in (j-o).

____2. Incident involved intimidation, harassment menacing or bullying of students or staff reported to the school principle or other school administrator responsible for student discipline by any source, such as a staff member, student, parent or other concerned citizen. Incident was not reported in Category 10 and did not result in a disciplinary action listed in the summary form (Columns j-o).

3. DATE AND TIME OF INCIDENT ___________________________________________

4. LOCATION OF INCIDENT _________________________________________________

5. INCIDENT OCCURRED (Check one item under each column)

Location	Time
____ (a) On school property 4(a)	___ (d) During regular school hours 4(c)
____ (b) At school-sponsored function off school grounds 4(b)	___ (e) Before or after regular school hours 4(d)

6. INCIDENT WAS (Check all that apply)

____ (a) Gang related 4(e)

____ (c) Bias Related 4(f)

7. VICTIMS (Duplicate this page as necessary)

Enrolled Students 1(e)

	Name	Grade	Age
1
2
3
4
5
6
7
8
9
10

School Personnel 1(f)

1	Name	Position
2
3
4
5
6
7
8
9
10

Others (Include Unknown) 1(g)

1	Name	Position
2
3
4
5
6
7
8
9
10

8. OFFENDERS (Duplicate this page as necessary)

Enrolled Student 1(b)

Name:____________________________________ Grade ___ Age ___

Check all that apply. Report duration in school days. (√) Duration

Referred for counseling or treatment program 1(j)

Removed by teacher (section 3214) 1(k)

Suspension from Class or Activities 1(l)

Received out-of-school suspension 1(m)

Transferred to alternative education program 1(n)

Referred to law enforcement or juvenile justice 1(o)

Other non-punitive referrals (not to be reported on annual summary form) ______________________________________________________________________

Enrolled Student 1(b)

Name:____________________________________ Grade ___ Age ___

Check all that apply. Report duration in school days.