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Includes certification by responsible staff plus three supporting attachments: a student screening form to assess intoxication, injuries, medication carry, and breathalyzer results; a referral checklist requiring brief narratives and involved-student listing; and an observation form with scheduled check intervals and tabulated observation entries.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/incident-report-form-student-alcohol-or-drug-related-incident-biographical-information-screening-referral-observation-certification/244999/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/incident-report-form-student-alcohol-or-drug-related-incident-biographical-information-screening-referral-observation-certification/244999.png","ImageObject",442,249,{"name":42,"@type":43},"Nguyễn Văn Học","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-12",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",7,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be completed in Part I of the incident report?","Question",{"text":63,"@type":64},"Part I collects the school’s name, incident date and time, student’s name, age, grade, incident location, and whether it is an offense or alcohol/drug related matter.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"How is the student screening form used and what does it record?",{"text":68,"@type":64},"The screening form is completed by staff making initial contact with an intoxicated-looking student. It records answers to specific questions about alcohol or drugs, medication possession and inquiry, physical injury signs, violence/behavior risk, and breathalyzer results.",{"name":70,"@type":61,"acceptedAnswer":71},"What check interval should staff use on the observation form?",{"text":72,"@type":64},"If the student is intoxicated, staff document checks every fifteen minutes; if not intoxicated, observations are recorded every thirty minutes, with initial entry observations logged in Table 1.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},244999,1789223884,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":33,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":26},1374402739827,"https://ap-avatar.wpscdn.com/avatar/14000c97e7351f1a627?x-image-process=image/resize,m_fixed,w_180,h_180&k=1787885694763230660","Part I: Biographical Information  \nSchool’s Name:   Incident’s Date and Time:   Student’s Name:   Age:   Grade:  Incident’s Location: [ ] School [ ] Dorm [ ] Other (specify):    \nSchool Category or Offense:  If the incident is alcohol or drug related, complete Attachments A, B, and C.  \nName of Other Involved Name of Other Involved Name of Other Involved Name of Other Involved Part II: Incident's Description (e.g., what happened and who was involved?)—attach additional sheets as needed:  \nPart III: Action Taken:  \nPart IV: People who were notified of the incident:  \n[ ] Parent/Guardian:   Date and Time:  [ ] Law Enforcement:   Date and Time:  [ ] Hospital/EMT:   Date and Time:    \n[ ] Education Line Office:   Date and Time:   Did student acknowledge the report? [ ] No [ ] Yes, when:    \nPart V: Certification  \nI certify that the information contained in this report is true and correct to the best of my knowledge.  \nSignature Date Telephone Number  \nAttachment A: Student Screening Form  \nStudent’s Name:   Date:    \nGeneral medical information will be in the student’s school medical file. This screening form is to be completed by the staff making the initial contact with a student who appears intoxicated.  \nAnswer the following questions and record breathalyzer results:  \n1. Does the student appear to be under the influence of alcohol or drugs? [ ] Yes [ ] No  \n2. Is the student carrying any medications? [ ] Yes [ ] No  \n3. Did you ask the student if he or she was on any medications? [ ] Yes [ ] No  \n4. Does the student have any signs of physical injury? [ ] Yes [ ] No  \n5. Is the student out of control or physically violent to self and/or others? [ ] Yes [ ] No  \n6. Breathalyzer results:    \nIf you detect or observe any other health problems, please explain:  \nCheck results of the student’s screening assessment:  \n1. [ ] Student was transported to the emergency room  \n2. [ ] Student was accompanied by a staff member to sick bay, transition dorm, or dorm of origin  \n3. [ ] Other, please explain:    \n4. [ ] Referral from (Attachment B) completed and forwarded  \nStaff’s Name (print) Date and Time  \nStaff’s Signature  \nAttachment B: Referral Checklist  \nStudent’s Name:   Date:    \n1. [ ] Student has possession of alcohol or drugs  \n2. [ ] Student displays visible signs of alcohol of drug use  \n3. [ ] Student is sleeping off alcohol or drugs  \n4. [ ] Student is self-referred for alcohol or drugs  \nDescribe in a brief written narrative what symptoms the student demonstrated or what activities led to this student’s referral:  \nPlease list other students who were involved in this activity:  \nStaff’s Printed Name or Student Making the Referral   \nStaff’s Signature or Student Making the Referral Date  \nNote: The student assistance team will receive a copy of the completed and signed referral checklist the next day.  \nAttachment C: Observation Form  \nStudent’s Name:   Date:    \nIf the student is intoxicated, document that the student is checked every fifteen minutes. If the student is not intoxicated, record observations every thirty minutes. Use additional forms as needed.  \nUpon initial entry to the sick bay/transition dorm or dorm of origin, staff will record student observations in Table 1.  \nTable 1: Observation Entries  \n\n| Time | Observation | Initials | Time | Observation | Initials |\n| --- | --- | --- | --- | --- | --- |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n\n\n| Staff on Duty |\n| --- |\n| Staff on Duty |\n| Staff on Duty |\n\nStaff on Duty  \n\n| Time in |\n| --- |\n| Time in |\n| Time in |\n\nTime in  \n\n| Time out |\n| --- |\n| Time out |\n| Time out |\n\nTime out","cbCaihtdU2Y98hmi","https://ap.wps.com/l/cbCaihtdU2Y98hmi","pdf",211406,"English","# Part I: Biographical Information\n# Part II: Incident's Description\n# Part III: Action Taken\n# Part IV: People who were notified of the incident\n# Part V: Certification\n# Attachment A: Student Screening Form\n# Attachment B: Referral Checklist\n# Attachment C: Observation Form","[{\"question\":\"What information must be completed in Part I of the incident report?\",\"answer\":\"Part I collects the school’s name, incident date and time, student’s name, age, grade, incident location, and whether it is an offense or alcohol/drug related matter.\"},{\"question\":\"How is the student screening form used and what does it record?\",\"answer\":\"The screening form is completed by staff making initial contact with an intoxicated-looking student. It records answers to specific questions about alcohol or drugs, medication possession and inquiry, physical injury signs, violence/behavior risk, and breathalyzer results.\"},{\"question\":\"What check interval should staff use on the observation form?\",\"answer\":\"If the student is intoxicated, staff document checks every fifteen minutes; if not intoxicated, observations are recorded every thirty minutes, with initial entry observations logged in Table 1.\"}]","Incident Report Form - Student Alcohol or Drug Related Incident - Biographical Information, Screening, Referral, Observation, Certification | PDF"]