NJ EVVRS VV-SA Incident Report Form

Introduction

This report is used to report EVVRS and/or HIB information from Incident Management. Only NJ EVVRS State Reportable incidents are included.

Note: This report is no longer used for state reporting purposes. It is has been replaced by the NJ SSDS Incident Report Form.

Selection Criteria

Selection criteria determine which database records are used in the report. For the Pre-ID Test Labels for NJ HSPA Tests extract, student and course enrollment records are selected.

Incident Type must be STATE REPORTABLE (EVVRS)^.
Incident Date must occur between the Report Start Date and Report End Date.
Incident School, not Participant School, will be used to select the Incidents to report (unless run from the District Office and the "All Schools" option is selected).
Only Offenders and Victims will be reported.
Offender information will be included for as many Offenders as are defined for an Incident.
Victim information will be included for as many Victims as are defined for an Incident.
If the Incident has a HIB Protected Category attribute associated with the Incident, then Page 2 (HIB Information) will be included; otherwise, Page 2 will be skipped.
Data field size limitations:
- Only the first 300 characters of the Incident Description (Page 1) will be reported.
- Only the first 150 characters of a HIB Offender's "Other Measures Imposed" comment (Page 3) will be reported.
- Only the first 60 characters of a HIB Victim's "Other Measures" comment (Page 4) will be reported.

Report Input

For help with navigation and running the report, see How to Find and Generate a Report.

Field	Description
Select Schools	If run at the district level, choose one of the following: Select Multiple Schools – Select schools to include in the report from the list. All Schools – Run the report for the entire district. If run at the school level, choose one of the following: Current School Only – Includes all student records associated with the current school that meet the selection criteria. To change the current school, click School at the top of the page and choose the appropriate school from the list. All Schools – Includes all student records on the PowerSchool server that meet the selection criteria.
Select School Year	Select a school year for the report to extract from.
Incident Start Date (will report incidents on or after this date)	Enter a start date for the report.
Incident End Date (will report incidents on or before this date)	Enter an end date for the report.
Output Option	Choose one of the following from the pop-up menu: Submission-ready – The output will be identical with what should be submitted to the State EVVRS and available as hard copy for legal reasons. For Verification purposes – The output will include all available details on the Incident, some of which are not submitted in EVVRS.

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Report Output

Each of the fields displayed in the output of the report is described below. See Understanding the Report Output Table for a definition of each column in the table.

The following report output table includes all available details on the incident, including those not submitted in EVVRS.

Item #	Data Element	Description	[Table]FieldName	Field Length
1	System-Assigned Incident Number	The incident identification.
2	Local Incident Number (Optional)	The incident ID assigned by the district.	[Incident]Incident_ID	10
Incident Header
3	School Name	The name of the school reporting the incident.	[Schools]Name	60
4	Location	A check mark next to one or more of the following indicates the location(s) of the incident: Cafeteria Classroom Corridor Other Inside School School Entrance Building Exterior Other Outside Bus Locker Room Off-site School-Sponsored Function Other School Grounds (HIB only) Off-site Program	[Schools]NJ_Location_Code
5	Date of Incident	The date the incident occurred.	[Incident]Incident_TS	6
6	Time of Incident	The time the incident occurred.	[Incident_Detail]LU_CODE_ID [Incident_Detail]LU_SUB_CODE_ID	10
7	Bias-Related	A check mark indicates that the incident was bias-related.	[Incident_LU_Code]Incident_Category	50
8	Gang-Related	A check mark indicates that the incident was gang-related.	[Incident_LU_Code]Incident_Category	50
9	Police Notification	A check mark indicate which of the following policy notifications ensued: None Police Notified, Complaint Filed Policed Notified, No Complaint Filed	[Incident_LU_Code]Incident_Category	50
10	Contact Name	The contact's name.	[S_Contacts_S]First_Name [S_Contacts_S]Last_Name	75
11	Contact Phone #	The contact's phone number.	[S_Contacts_S]Cell_Phone [S_Contacts_S]Home_Phone [S_Contacts_S]Work_Phone	30
Incident Type
12	Violence	A check mark next to one or more of the following indicates that the incident involved the particular form of violence: Criminal Threat Extortion Fight Threat Kidnapping Robbery Sex Offense	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
13	Vandalism Related	A check mark next to one or more of the following indicates that the incident was related to the particular form of vandalism: Arson Bomb Threat Burglary Damage to Property Fake Bomb Theft (>=$10) Trespassing Fire Alarm Offense Fireworks Offense	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
14	Harassment, Intimidation, or Bullying	A check mark indicates that the incident involved harassment, intimidation, or bullying.	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
15	Weapons - Possession/Used in Offense	A check mark next to one or more of the following indicates that the incident involved possession or use of the weapon: Handgun Rifle Air Gun, Pellet Gun, BB Gun Imitation Firearm Knife, Blade, Razor, Scissors, Box Cutter Pin, Sharp Pen/Pencil Chain, Club, Brass knuckles Spray Other	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
16	Weapons - Sale/Distribution of Weapon	A check mark indicates that the incident involved sale and/or distribution of weaponry.	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
17	Weapons - Bomb Offense	A check mark next to one of the following indicates that the incident involved a bomb: Bomb - exploded Bomb - unexploded	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
18	Substance Offense	A check mark next to one or more of the following indicates that the incident involved substance abuse: Use confirmed Possession Sale/Distribution	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
19	Substance Type	A check mark next to one or more of the following indicates that the incident involved the particular substance type: Alcohol Marijuana Amphetamines Designer/Synthetic Drugs (e.g., Party Drugs, Club Drugs, Bath Salts, Synthetic Marijuana, China White, Synthetic Heroin (MPTP), Ecstasy (MDMA), GHB, Rohypnol K2, Spice, Cloud Nine (MDPV Cocaine/Crack Hallucinogens (e.g., THS, LSD, Jimson Weed, Angel Dust (PCP), Psilocybin (Mushrooms), DMT, Ketamine, Mescaline (Peyote)	[PSRW_ParticipantBehavior]State_Detail_Report_Code	50
20	Incident Description	The report extracts the incident description.	N/A	N/A
Harassment, Intimidation, or Bullying (HIB) Information
21	Lead Investigator First Name	The incident lead investigator's first name.	[Incident_LU_Code]Incident_Category	50
22	Lead Investigator Last Name	The incident lead investigator's first name.	[Incident_LU_Code]Incident_Category	50
23	Protected Category	A check mark next to one or more of the following indicates that the victim belongs to the particular protected category: Race Color Religion Ancestry Origin Gender Sexual Orientation Gender Identity & Expression Mental, Physical, or Sensory Disability Other Distinguishing Characteristics	[Incident_LU_Code]Incident_Category	50
24	Effect of HIB Incident	A check mark next to one or more of the following indicates the effect of the incident on the victim and/or offender: Offender knew action would physically or emotionally cause harm to the victim or damage to the victim's property Victim was in fear of physical or emotional harm or damage to personal property Insulted or demeaned a student or a group of students Interfered with victim's education Created a hostile educational environment by severely or pervasively causing physical or emotional harm to the student	[Incident_LU_Code]Incident_Category	50
25	Mode of HIB Incident	A check mark next to one or more of the following indicates the offender's mode of harassment, intimidation, or bullying: Gesture Written Verbal Physical (major or minor injury) Electronic Communication	[Incident_LU_Code]Incident_Category	10
Offender Information
26	Offender Type	A check mark next to one of the following indicates the type of offender in the incident: General Education Student Student with Disabilities Student from Another School Non-student Unknown	[PSRW_IncidentParticipant]Role_Subcode	50
27	Removal	A check mark next to one of the following indicates the kind of action taken: Yes - Select action(s) taken from section A and/or B No - Select action(s) taken from section C	[PSRW_IncidentAction]Incident_Category	50
28	Disciplinary action(s) taken and days Suspended or removed	See sections A, B, and C.	N/A	N/A
29	Section A	A check mark next to one of the following indicates the type of student and the action taken: All Students In-school Suspension [number] days Out-of-school Suspension [number] days General Education Students Only [number] Expulsion	[PSRW_IncidentAction]Incident_Category	50
30	Section B	A check mark next to one of the following indicates the type of student and the action taken: Students with disabilities only Unilateral removal [number] Days (< 45) Removal by ALJ for Dangerousness [number] Days	[PSRW_IncidentAction]Incident_Category	50
31	Section C	A check mark next to one of the following indicates the type of student and the action taken All Students None Detention Other Suspension of Privileges	[PSRW_IncidentAction]Incident_Category	50
32	Remedial Action(s) taken for HIB only	A check mark next to one or more of the following indicates the remedial action(s) taken: Restitution and Restoration Individual Counseling Referral for therapy/treatment Student Conference Group Counseling Transfer Parent Conference Referral to the Intervention and Referral Services Team Other measures imposed [specified]	[PSRW_IncidentAction]Incident_Category	50
33	Program/Services Provided upon Disciplinary Action	A check mark next to one or more of the following indicates the programs and services provided upon disciplinary action: None Assignment(s) Academic Instruction (only) Support Services (only) Educational Program (Academic Instruction and Support Services)	[Incident_LU_Code]Incident_Category	50
34	Location of Program/Services	A check mark next to one or more of the following indicates the location(s) of the programs/services: In-school Setting In-district Alternative Education Program Other In-district Setting Home (includes home instruction) Out-of-district Alternative Education Program Other Out-of-district Setting	[Incident_LU_Code]Incident_Category	50
35	Offender Caused	A check mark next to one of the following indicates the level of injury the offender caused the victim: Minor injury Major injury No injury	[PSRW_ParticipantActionAttr]Sub_Category	50
36	Offender incurred	A check mark next to one of the following indicates the level of injury the offender incurred: Minor Injury Major injury No injury	[PSRW_ParticipantActionAttr]Sub_Category	50
37	Only for students with disabilities causing a major injury	Did the offender cause Serious Bodily Injury, defined as an injury which involves (A) a substantial risk of death; (B) extreme physical pain; (C) protracted and obvious disfigurement; or (D) protracted loss or impairment of the function of a bodily member, organ, or mental faculty? Yes No	[PSRW_ParticipantActionAttr]Sub_Category	50
38	Student First Name	The student offender's first name.	[PSRW_IncidentParticipant]First_Name	30
39	Student Last Name	The student offender's last name.	[PSRW_IncidentParticipant]Last_Name	30
40	State NJSMART Student ID	The unique number assigned and maintained by the New Jersey Department of Education for this student.	[Students]State_StudentNumber	10
41	Gender	A check mark next to one of the following indicates the offender's gender: Male Female	[Students]Gender	2
42	Ethnicity	A check mark next to one of the following indicates the offender's ethnicity: Hispanic Non Hispanic	[Students]Ethnicity	20
43	Race	A check mark next to one or more of following indicates the offender's race: American Indian, Alaskan Native Asian Black, African American Native Hawaiian or Other Pacific Islander White	[Students]FedEthnicity	10
44	Grade	A check mark next to one of the following indicates the offender's grade level: K 1 2 3 4 5 6 7 8 9 10 11 12	[Students]Grade_Level	2
45	Student Disability Category for Federal Reporting	A check mark next to one or more of the following indicates the offender's disability: 01 Hearing Impairments 02 Autistic 03 Intellectual Disability - Mild Cognitive Impairment 04 Intellectual Disability - Moderate Cognitive Impairment 05 Intellectual Disability - Severe Cognitive Impairment 06 Communication Impaired 07 Emotional Disturbance 08 Multiple Disabilities 09 Deaf-blindness 10 Orthopedic Impairments 11 Other Health Impairments 14 Specific Learning Disabilities 15 Traumatic Brain Injury 16 Visual Impairments 17 Speech or Language Impairments	[Incident_LU_Code]Incident_Category	50
46	LEP	A check mark indicates that the student has limited English proficiency status.	[S_NJ_STU_X]State_LEP_Status	3
47	Section 504	A check mark indicates that the student is eligible for Section 504 programs.	[S_STU_CRDC_X]Section504_YN	1
Victim Information
48	Victim Type	A check mark next to one of the following indicates the type of victim in the incident: General Education Student Student with Disabilities Student from Another School Non-student School Personnel Identifiable Group None	[PSRW_IncidentParticipant]Role_Subcode	50
49	Victim Incurred	A check mark next to one of the following indicates the level of injury the victim incurred: Minor Injury Major Injury Serious Bodily Injury No Injury Incurred	[PSRW_ParticipantActionAttr]Sub_Category	50
50	Remedial Action(s) taken for HIB only	A check mark next to one or more of the following indicates the remedial action(s) taken: Counseling Support Services Intervention and Referral Services Parent Conference Before/After School Supervision Schedule change School transportation supervision School transfer Teacher Aide/Monitor during school day Peer Support Group Adult-Student Mentoring Restitution/Restoration Seating change Alternate Placement Assessment/Evaluation Out-of-School Mental Health Service Other Measures [specified]	[PSRW_IncidentAction]Incident_Category	50
51	Student First Name	The student victim's first name.	[PSRW_IncidentParticipant]First_Name	30
52	Student Last Name	The student victim's last name.	[PSRW_IncidentParticipant]Last_Name	30
53	State NJSMART Student ID	The unique number assigned and maintained by the New Jersey Department of Education for this student.	[Students]State_StudentNumber	10
54	Gender	A check mark next to one of the following indicates the victim's gender: Male Female	[Students]Gender	2
55	Ethnicity	A check mark next to one of the following indicates the victim's ethnicity: Hispanic Non Hispanic	[Students]Ethnicity	20
56	Race	A check mark next to one or more of following indicates the victim's race: American Indian, Alaskan Native Asian Black, African American Native Hawaiian or Other Pacific Islander White	[Students]FedEthnicity	10
57	Grade	A check mark next to one of the following indicates the victim's grade level: K 1 2 3 4 5 6 7 8 9 10 11 12	[Students]Grade_Level	2
58	Student Disability Category for Federal Reporting	A check mark next to one or more of the following indicates the victim's disability: 01 Hearing Impairments 02 Autistic 03 Intellectual Disability - Mild Cognitive Impairment 04 Intellectual Disability - Moderate Cognitive Impairment 05 Intellectual Disability - Severe Cognitive Impairment 06 Communication Impaired 07 Emotional Disturbance 08 Multiple Disabilities 09 Deaf-blindness 10 Orthopedic Impairments 11 Other Health Impairments 14 Specific Learning Disabilities 15 Traumatic Brain Injury 16 Visual Impairments 17 Speech or Language Impairments	[Incident_LU_Code]Incident_Category	50
59	LEP	A check mark indicates that the student has limited English proficiency status.	[S_NJ_STU_X]State_LEP_Status	3
60	Section 504	A check mark indicates that the student is eligible for Section 504 programs.	[S_STU_CRDC_X]Section504_YN	1
61	Victim of a Violent Criminal Offense?	A check mark indicates whether or not the student was a victim of a violent criminal offense: Yes No	[Incident_LU_Code]Incident_Category	50
62	Transfer Option Available?	A check mark indicates whether or not the student has the option to transfer schools: Yes No	[Incident_LU_Code]Incident_Category	50
63	Outcome	A check mark indicates the status of the student's option to transfer: Transfer Option Accepted, Transfer Completed Transfer Option Accepted, Transfer Not Completed Transfer Option Declined	[Incident_LU_Code]Incident_Category	50

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