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Safety Concerns
This form is available for any student, staff, and family/community member who has a safety concern related to a SASED student, staff member, or school/program.
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* Indicates required question
I am a:
*
Choose
Student
Employee
Parent
Community Member
What SASED program or service is involved in the concern?
*
Assistive Technology
Audiology
Deaf & Hard of Hearing (DHH)
Directions
Itinerants (Hearing Itinerants, Occupational Therapy, Orientation & Mobility, Physical Therapy, Vision Itinerants)
Multi-Needs
Project Search
School Improvement/Instructional Support
Southeast
STARS
Transition
Vision
Other:
Required
Event Description (include who, what, when, where and how do you know)
*
Your answer
Concern/Event Type:
Choose
Anger Issues
Animal Cruelty
Bullying/Cyber Bullying
Concern about an Adult
Cutting/Self-Harm
Depression/Anxiety
Domestic Violence/Child Abuse
Drug Use/Distribution
Eating Disorder
Gang Violence/Activity
Harassment/Intimidation
Hate Crime/Hate Speech
Hazing
Homeless/Runaway
Inappropriate Relationship
Intent to Harm Someone
Physical Abuse
Planned Fight/Assault
Planned School Attack
Practice Tip
Reckless/Dangerous Behavior
Sexual Assault/Rape
Sexual Exploitation/Abuse
Sexual Harassment
Sharing Inappropriate Photos
Social Isolation/Withdrawal
Suicide/Suicide Ideation
Theft
Toxic/Abusive Relationship
Vandalism
Verbal Abuse
Weapon(s)
Other
Who are you concerned about?
Please provide as much of the following information about the person(s) of concern as possible:
Name of first person of concern:
Your answer
Involvement of person 1:
Choose
Target
Aggressor
Witness
Grade & Age of person 1
Your answer
Race/Ethnicity of person 1
Choose
African American
Asian
Latinix
Native American
Two or more
White
Other
School/Location of person 1:
Your answer
City/Town of person 1:
Your answer
Description of Physical Appearance/Clothing of person 1:
Your answer
Is there another person involved?
*
Yes
No
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