2010-2011

Report of Suspension of Students with Disabilities

for reasons other than violence, vandalism, weapons or substance abuse

for the Electronic Violence and Vandalism Reporting System (EVVRS)[1]

Use this form to report the suspension of students from their IEP placement for reasons other than violence, vandalism, weapons and substance abuse (VV-SA). To report an incident of violence, vandalism or substance abuse (e.g., fight, threat, damage to property), use the Incident Report Form. In accordance with federal requirements, report all in-school suspensions (that is, any removal from the classroom lasting at least one-half day) of students with disabilities whether or not the student receives IEP services during the in-school suspension.[2]

School ______________________________

Incident Information

Incident Number: ________________ (System-generated upon data entry)

Location of Incident: cafeteria, classroom, corridor, other inside school, school grounds, bus, building exterior, district office, other outside, off-site program, school entrance.

Date of Incident: ________________ Time of Incident: ___________ Bias: Y / N

Police Notification: ___none ____notified and complaint filed ___notified and no complaint filed

Gang Related: Y / N Contact Name: __________________ Phone: __________________

Incident Type (check one): Minor physical altercation (e.g., scuffle): ____ Other: ____

Brief Description of the Reason for the Suspension: _______________________________

 ___________________________________________________________________________

Offender Information Page

Student ID#:________________________ Removal (from class): Must be ‘Yes’

Action Taken (check): Days Suspended:

____ In-School Suspension ____

____ Out-of-School Suspension ____

Program Provided Upon Disciplinary Action: ___ None ___ Assignment(s) ___ Academic Instruction (only) ___Support Services (only) ___Educational Program (Instruction & Support)

Location of Program/Services:

___ In-school setting ___*In-district alternative educational program ___ Other in-district setting

___Home (includes home instruction) ___*Out-of-district alternative educational program

___ Other out-of-district setting

* District Board of Education or Department of Education approved only

Student Offender Information

State (NJSmart) ID___________________First Name: ______________ Last Name: ___________

Gender: __Male __Female

Grade of student in school: ____

Ethnicity: ___Hispanic ___Non-Hispanic

Race: ___American Indian or Alaska Native ___Asian ___Black or African American

___Native Hawaiian or Other Pacific Islander ___White

Student Disability Category (check one category only):

___ Autism ___ Deaf-Blindness ___ Emotional Disturbance ___ Hearing Impairments

___ Mental Retardation ___ Multiple Disabilities ___ Orthopedic Impairments

___ Other Health Impaired ___ Specific Learning Disabilities ___ Speech-Language Impairments

___ Traumatic Brain Injury ___ Visual Impairments

Limited English Proficient (LEP): __Yes __No Section 504: __Yes __No

Student Victim Information (if applicable)

Victim Type: ___ General education student ___ Student with disabilities ___ Student from

another school ___ Non-student ___ School personnel ___ Identifiable group

Student ID#:________________________

First Name: ___________ Last Name: ______________ Gender: ___ Male ___ Female

Ethnicity: ___Hispanic ___Non-Hispanic

Race: ___American Indian or Alaska Native ___Asian ___Black or African American

___Native Hawaiian or Other Pacific Islander ___White

Grade of student in school: _____

If eligible for Special Education, check Disability Category (Omit if not classified)

Student Disability Category (check one category only):

___ Autism ___ Deaf-Blindness ___ Emotional Disturbance ___ Hearing Impairments

___ Mental Retardation ___ Multiple Disabilities ___ Orthopedic Impairments

___ Other Health Impaired ___ Specific Learning Disabilities ___ Speech-Language Impairments

___ Traumatic Brain Injury ___ Visual Impairments

Limited English Proficient (LEP): __Yes __No Section 504: __Yes __No

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[1] Available at http://homeroom.state.nj.us – EVVRS.

[2] An in-school suspension is defined by IDEA reporting requirements as an instance in which a child is temporarily removed from his/her regular classroom(s) for disciplinary purposes but remains under the direct supervision of school personnel.  Direct supervision means school personnel are physically in the same location as the student under their supervision.