Referral for Substance Use Intervention
This form should be utilized to report a student you suspect to be currently under the influence or in possession of drugs and/or alcohol.

Please fill out all fields below and hit submit.  

NOTE: There is no need for you to reach out to the student or parent to advise of your referral.

[Be assured that all information reported below is confidential and protected under Federal Confidentiality Law 42 CFR Part 2. ]

Should you have any questions, please reach out to the SAC Department supervisor, Ms. Laurel Olson, at 973-321-0694 or lolson@paterson.k12.nj.us
Email *
Today's Date *
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Date of Incident (if different from above)
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Time of Incident (can be estimated if unsure): *
Time
:
Your Name: *
School Name: *
Student Initials: *
Student ID#: *
Student's grade level: *
Student's guardian name (if you have no access to Infinite Campus to collect this information, please write UNKNOWN): *
Student's guardian phone number  (if you have no access to Infinite Campus to collect this information, please write UNKNOWN): *
Gender  *
Student's ethnicity/race (if you have no access to Infinite Campus to collect this information, please select UNKNOWN):
 *
Is the student classified (Sp.Ed.)? *
Location of use/possession: *
Student suspicion/possession of (select all that apply): *
Required
What are some observed appearances you saw? (check all that apply): *
Required
What are some observed behaviors you saw? (check all that apply): *
Required
Please write a brief description of the incident below: *
Are there any other comments you would like to add?
A copy of your responses will be emailed to .
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