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Newport-Mesa USD |  E  1310  Community Relations

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Exhibit 1

CIVILITY INCIDENT REPORT

Today's Date: ___________________

Site/Location where incident occurred:

Name of person completing incident report:

Name of Person being reported:

Is this person a parent/guardian or relative to a student at NMUSD

Did you feel your well being was threatened?

Were there witnesses to this incident? If so, name them:

Were the police contacted? ___________________

Describe the incident and what happened:

Signature of person completing this report:

Incident Report was received by:

Action taken by Site/Department Administrator:

Please make three copies of completed document:

Retain one copy

Send one copy to your Site/Department Administrator

Send one copy to the Superintendent's Office

Exhibit NEWPORT-MESA UNIFIED SCHOOL DISTRICT

version: September 8, 2009 Costa Mesa, California