Use this form to report the suspension or removal of students from their IEP placement for reasons other than violence, vandalism, weapons and substance abuse (VV-SA). Do not use this form to report a VV-SA incident e.g., fight, threat, damage to property; instead, use the Incident Report Form to report a VV-SA incident. According to federal guidelines, all in-school suspensions of students with disabilities should be reported whether or not the student receives IEP services during the in-school suspension.[1] Do not report in-school suspensions lasting less than one full day when using this form, however.

District ______________________________ School ______________________________

Incident Information

Incident Number: ________________ The EVVRS generates the incident number upon data entry.

Location of Incident: (Circle one) cafeteria, classroom, corridor, other inside school, school grounds, bus, building exterior, district office, other outside, off-site program (______________)

Date of Incident: ________________________ Time of Incident: _______________

Contact Name: _________________________ Contact Phone: ________________

Brief Description of the Reason for the Suspension: _______________________________

 ___________________________________________________________________________

Offender Page Information

Student ID: _________________

Decision of Office of Administrative Law (OAL) Judge? (through a Due Process Hearing because student was likely to injury themselves or others): Yes ___ No ___

Disciplinary Action Taken (Circle one): None; Expulsion; Short-term suspension*; Long-term suspension*; Detention, Other (specify): ___________________________________

Number of Days Suspended or Removed for this Incident: _________________

Program Provided Upon Disciplinary Action: (Circle one): Home instruction, In-district alternative program/school; Other in-district setting; Out-of-district alternative program/school; Other out-of-district setting (specify: ____________________________) In-school suspension

*Short-term suspension denotes 10 or fewer consecutive days; long-term suspension, more than 10 days, per N.J.A.C. 6A:16-7.2,7.3

Student Offender Information

First Name: ______________ Last Name: _________________ Gender: Male Female

Continued on page 2 of this form.

Racial/Ethnic Group (Circle one):

American Indian or Alaskan Native	Hispanic or Latino
Asian or Pacific Islander	White
Black or African American

Eligibility Category (Circle one)

Autism	Mental Retardation	Specific Learning Disabilities
Deaf-Blindness	Multiple Disabilities	Speech-Language Impairments
Emotional Disturbance	Orthopedic Impairments	Traumatic Brain Injury
Hearing Impairments	Other Health Impaired	Visual Impairments

Limited English Proficient (LEP): Yes No Section 504: Yes No

Victim Information (if applicable)

ID number: ________ First Name: ________ Last Name: ___________ Gender: Male Female

Racial/Ethnic Group (Circle one):

American Indian or Alaskan Native	Hispanic or Latino
Asian or Pacific Islander	White
Black or African American

If eligible for Special Education, circle Eligibility Category (Omit if not disabled)

Autism	Mental Retardation	Specific Learning Disabilities
Deaf-Blindness	Multiple Disabilities	Speech-Language Impairments
Emotional Disturbance	Orthopedic Impairments	Traumatic Brain Injury
Hearing Impairments	Other Health Impaired	Visual Impairments

Please forward the completed form to the person responsible for entering the suspension/removal data of students with disabilities on the Electronic Violence and Vandalism Reporting System (EVVRS) – http://homeroom.state.nj.us – EVVRS.

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[1] An in-school suspension is 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.