| Persons attending review meeting:
______________________________________________________________
(Suggested attendees: principal, teacher, public health nurse, parent(s)/guardian(s), and relevant school staff) Date of Report: _______________________ Time: _________________________ Name of School: _______________________________________________________ Person Completing Form: ________________________________________________ |
|
Nature of Concern/Incident: __________________________________________________ ______________________________________________________________ Date Concern/Incident Occurred: ______________________ Time: _________________ Place: ___________________________________________________________________ Individuals Involved: _______________________________________________________ (request attendance at review meeting) _________________________________________________________________________ |
| Details of the Concern/Incident*:
(attach a separate sheet of notes if required) Actions Taken: Follow-up plan & date: |
| *Gather Information: What happened before, during and after the incident? Your response? Their response (Include words and actions)? Witnesses? How did it end? Previous report of concern/incident? |
|
Signature of Principal: ___________________________________ Signature of PHN: ______________________________________ Signature of Parent/Guardian: _____________________________ |
| Copies to:
Student’s file School Board Office Parent Public Health Nurse |