STUDENTWITNESS STATEMENT -OPTIONAL

							                                                                                                   Exhibit IIB
                                                                                             File Code: 5114

                                          The Newark Public Schools
                                             Newark, New Jersey


                           STUDENT/WITNESS STATEMENT -OPTIONAL
                             (To be completed and submitted to Principal) - OPTIONAL


SCHOOL ______________________                                DATE __________________


Date of Incident_________________                            Time of Incident_____________

Reported by____________________                              Position____________________

Reported to____________________                              Position____________________

Names of individuals involved (if any):


Description of incident:




Submitted by _______________________Date______________________



______________________
Student Signature