Behavior Incident Form

Meinders Community Library Board Policy 700
Policy: Behavior Incident Form Originally Adopted Next Review
Current Version Adopted January 9, 2019 6/2014 November 2022

DATE: ____________________       TIME: ___________________

Name of Person(s) involved: ______________________________________________________

______________________________________________________________________________

Telephone of Person(s) involved: __________________________________________________

______________________________________________________________________________

Names, telephone numbers, addresses of witness(es): __________________________________

______________________________________________________________________________

______________________________________________________________________________

Description of Incident: __________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Name of Staff Involved: __________________________________________________________

______________________________________________________________________________

Action Taken by Staff: ___________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Length of Suspension: ___________ Start Date: ______________  End Date: _____________

Were Police Called: ______________________

Name of Reporting Officer: ______________________________________________________

What action did Police take: ______________________________________________________

_____________________________________________________________________________

______________________________________________________________________________

Date report filed: _______________________________________________________________

Date Forwarded to Director: ______________________________________________________

Action taken by Director: ________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Library Board Action Required: ___________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Additional Notes: