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Santa Clara USD |  E  3515.2  Business and Noninstructional Operations

Disruptions   

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SANTA CLARA UNIFIED SCHOOL DISTRICT

SANTA CLARA, CALIFORNIA

Name_____________________________ Site________________________________

Date and Time (approximate) of Incident _________________________________

Location of Incident: (office, classroom, hallway, etc.)_________________

Name of person you are reporting (if known)

______________________________________

Is this person a parent/guardian or relative to a student at SCUSD?

___Yes ___No

Were there any witnesses to this incident? ___ Yes ___ No

Name of witness(es)______________________________________________________

Were the police contacted? ___ Yes ___ No

Name and title of site administrator notified____________________________

Was the person you are reporting, notified to leave the campus and not to return in accordance with California Education Code 44811 and Penal Codes 415.5 and 626.7?

___ Yes ___ No

If yes, by whom________________________________________________________

Was a written copy of this policy, provided to the person you are reporting? __Yes __ No

Below, please describe what happened: (if you need additional space, please use the back of this sheet)

_____________________________________________________

Name and Title of Person Completing Form

_____________________________________________________

Signature of Person Completing Form

_____________________________________________________

Date

Exhibit SANTA CLARA UNIFIED SCHOOL DISTRICT

version: September 26, 2013 Santa Clara, California