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Burbank USD |  E  1313  Community Relations

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BURBANK UNIFIED SCHOOL DISTRICT

Burbank, California

INCIDENT REPORT

Name ______________ Site_________________

Today's Date _______ Date and approximate time of incident

Name of person being reported (if known)_________

Is this person a parent/guardian or relative to a student in the district? ___ Yes ___ No

Did you feel your well being/safety was threatened?

___ Yes ___ No

If yes, please explain:

________________________________________

_________________________________________

Was there a witness(es) to this incident?

___ Yes ___ No

Name(s) of witness(es):__________________

Were the police contacted?

___ Yes ___ No

In the space provided below, please describe the incident:

(If you need additional space, please use the back of this sheet.)

____________________________________

Signature of person completing form

A copy of this Incident Report shall be maintained at the school site/department, and one copy sent to the Superintendent's Office.

Exhibit BURBANK UNIFIED SCHOOL DISTRICT

version: April 19, 2007 Burbank, California