Test Security Incident Report Form


In accordance with the Family Educational Rights and Privacy Act of 1974 (FERPA), please do not include any confidential or personally identifiable information regarding students when submitting this incident report form. Initials only should be used for student names.

* Denotes a required field

Contact Information:
* First Name:
* Last Name:
*Phone Number:
() -
Alt. Phone Number:
() -
*Email Address:
Position:

Allegation:
Name of the person(s) involved in the incident:
* Provide a detailed description of the incident:

Include: A detailed description of a) what happened b) on what date c) who was involved d) how you learned about it and e) any others who know about or witnessed the incident. Please use initials for first and last names of any student discussed.
Incident Location:
* Name of School District:

- OR -

* Name of BOCES:

* Name of School:

* Please check the box of each state exam affected:

English Language Arts (3rd - 8th Grade)
3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Mathematics (3rd - 8th Grade)
3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade

Science (4th and 8th Grade)
4th Grade 8th Grade

Regents
Integrated Algebra Geometry Algebra 2/Trigonometry Comprehensive English
Global History and Geography U.S. History and Government
Physical Settings/Chemistry Physical Settings/Physics
Physical Settings/Earth Science Physical Settings/Living Environment

Regents Competency Test (RCT)
Global Studies Mathematics Reading Science U.S. History and Government Writing

NYSESLAT (K - 12th Grade)
Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade

NYSAA (3rd - High School)
3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade High School

Other (3rd - 12th Grade)
3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade
9th Grade 10th Grade 11th Grade 12th Grade

* School Year of Exam Administration:

2010-2011 2011-2012 2012-2013 2013-2014 Other

or

Last Updated: January 28, 2014