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Directions: This is a form to report alleged gang activity and similar destructive or illegal group behavior or to report reprisal or retaliation against individuals who report gang activity and similar destructive or illegal group behavior or who are victims, witnesses, bystanders, or others with reliable information about an act of gang activity and similar destructive or illegal group behavior which occurred on school property, on school buses, or at school-sponsored events. Gang: "Criminal Gang" means a group or association of three or more persons whose members:
(1) individually or collectively engage in a pattern of criminal gang activity;
(2) have as one of their primary objectives or activities the commission of one or more underlying crimes, including acts by juveniles that would be underlying crimes if committed adults; and
(3) have in common an overt or covert organizational or command structure.

Gang Activity: "Pattern of criminal gang activity" means the commission of, attempted commission of, conspiracy to commit, or solicitation of two or more underlying crimes or acts by a juvenile that would be an underlying crime if committed by an adult.
(a) Activities on or near school vehicles or property. – A person may not threaten an individual, or a friend or family member of an individual with use of physical force or violence to coerce, induce, or solicit the individual to participate in or prevent the individual from leaving a criminal gang: (1) in a school vehicle, as defined under §11-154 of the Transportation Article; or (2) in, or within 1,00 feet of real property owned or leased to an elementary school, secondary school, or county board of education and used for elementary or secondary education.
(b) Applicability. – Subsection (a) of this section applies whether or not : (1) school was in session at the time of the crime; or (2) the real property was being used for purposes other than school purposes at the time of the crime.

Date: School: School System:
Person Reporting Incident First: Last:
Telephone: Email:

Specify Other:

1. Name of student victim:

First: Last: Student Age:

2. Name(s) of alleged offender(s)(if known):

First Name Last Name Age School Student?

3. On what date(s) did the incident happen?

4. Describe what occurred:

5. Where did the incident occur (choose all that apply?)

*Will be collected unless specifically excluded by local board policy

6. What did the alleged offender(s) say or do?

7. Why did the activity occur?

8. Did a physical injury result from this incident?

9. If there was a physical injury, do you think there will be permanent effects?

10. Was the student victim absent from school as a result of the incident?

If yes, how many days was the student victim absent from school as a result of the incident?

11. Did a psychological injury result from this incident?

12. Is there any additional information you would like to provide (e.g. name of gang, clique, crew, or group, if known)?

Signature (Type Full Name): Date: