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EXHIBIT

BUS  SAFETY  PROGRAM

SCHOOL  BUS  INCIDENT  REPORT

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Bus No.                                      Driver's Name                                         Date

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Type of Incident

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Student's Name

Incident:

◻       Failure to remain seated          ◻  Throwing objects on bus
◻       Refusing to obey driver            ◻  Hanging out of window
◻  Fighting                                    ◻  Spitting
◻       Profanity                                  ◻  Disobeying bus monitor
◻       Lighting matches                      ◻  Bothering others (see comment)
◻       Smoking on bus                        ◻  Vandalism
◻       Throwing objects out of bus      ◻  Other (see comment)

Comments: ______________________________________________________________

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Signature: _____________________________________________________

Action taken by school: ___________________________________________

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Signature of School Official