Leh vleutial Student al Teaches Tirlowetion Rewer) Minnesota Department of Confidential Student Maltreatment Education Reporting Form Date submitted: _ 03-29-2017 REPORTER (name of person completing form) Reportor Is cor ‘Michuel Miller “Title: Princlpal Intern Phone: 612-244-9140 yandated RepororeQEBS No MDE Filo #. {MDE staff use only) nfidential undor Minnesota Statutes, soction 626.556. Name: ‘Address: 3350 N. Ath Ste ily: Mmeapalis state: MN zip: $5412 SCHOOL INFORMATION 18pm: 00 choot Dietiet Mirmeapolls Public Schools __ Program Name: MA ‘sono! Nama Ciyview Comnnnity School __Aaddrse: 3350.N. duh SL ‘iy: Mimeapolis_ Zip: 55412 Prone: 512-668-2276 (ex, 82276. Phone: WA PricipalDirector Renee Montague “transpotaion Company (necessary): Contact M/A ALLEGED VICTIM (Complete one reporting form for ‘each alleged victim) Name: SOUS, _Actdross. cy sot 2 arene Phone ___Altornate Phone Gondor GD Fonale__ oc AMAA cra: Me __Ethniiy: African Amerie Special Education: Yes Qe Disabilly Description: Currently in evaluation process ALLEGED OFFENDER a potion SR 005; SAMRAP. Gondor: Malo K Female _. ees icros MM a Ce Etholiy: White Prone ND Alternat Phones MA state Student ID: 0001000114258 Hooneds Yen X_No__H senso, name of Wenig boar: MDE Folder INCIDENT Date: 22947 srme:_2:30__Loclon(e.- bum, oss, lasroam mus) ‘Address (i dtferent than school: county: Nd ‘Witness Conte Infomation SS ees eee see eeteesceeeeeeeL Police Notiied: Yes__, No___Peoice Department. NA Police Contact. N/A Phone, Case No.: ‘hloged MalreatmentPyelealAbuso XX, Sowal Abuse. Neglok Unknown — Injury: Yes. No__ Unknown Dodoripton of Icon an Ilury: Please alach adtional page Fneeded)- see altachel ‘Minnesota Department of Edueation ‘hucent Meltroatment Progrern {1500 Highway 36 West, Roseville, MN SS113-4266 Reporting ine: 651-582-8546 Favc 651-797-2602 Email: md,student-maltrentnient@state.0.us June 2016Confidential Student and Teacher Information Removed Date Submitted: 3-29-17 Reporter: Michael Miller, Principal Intern at Cityview Community School Contact: 612-668-2270 (w) 612-244-9140 (c) Teacher Statement ‘Teacher Statement: (Student Name) was sitting in the wrong spot and distracting those around him. Teacher told him to go take a break. Gave him a choice you can sit where you are supposed to or you can go take a break. Student responded no, Teacher then said he would need to get behavior. Teacher counted down 5-4-3-2-1, Students know that if the teacher gets to 0, he is going to call behavior. Student went to take a break and then immediately returned to the wrong spot. Ushering student to the take a break spot. Did not grab student. Student continuously elbowed teacher as he walked him to the chair. Student punched the teacher. Yelled “get away from me.” Teacher grabbed both of the student's wrist and put him in a chair (against the wall). Teacher said, “we are not going to do this” and immediately let go of the student. Held the student for 1-2 seconds, The student then the student stood up and punched the teacher again, Then the teacher grabbed the students wrist and started walking to the door. After 1-2 seconds the teacher let go of the students wrist and again ushered the student using proximity. The student was then out of the room. Teacher communicated to the office that behavior was need and relayed some of the information about what happened. The teacher then closed the door, which was lacked, and resumed teaching. ‘Teacher statement from (Teacher Name); collected by Michael Miller. Staff Statements Staff Witness #1: (Student Name) was not doing his job and was shoving a chair into another student. (Teacher Name) asked (Student Name) to leave, he refused. (Teacher Name) grabbed one of (Student ‘Name)'s wrists and pulled him off the other student. (Student Name) then started pushing and hitting the teacher. (Teacher Name} pulled on students writes to walk him over to the chair. (Student Name) punched the teacher again. (Teacher Name) then grabbed both of the students wrist and pinned the student in a chair against the wall. He held the student there for 1-2 seconds. Both (Teacher Name) and (Student Name) stopped, (Student Name) stood up and did not hit the teacher again. (Teacher Name) again grabbed one of (Student Name)'s wrists and walked the student out of the classroom, (Teacher Name) yelled to the office for behavior support and then closed his classroom door, which was locked. (Student Name) remained out of the classroom for the remainder of class.Confidential Student and Teacher Information Removed Staff Witness #2: (Student Name) was upset at having to take a break and he was mumbling. I couldn't really understand what he was saying, (Student Name) pushed (Teacher Name) with both hands. (Teacher Name) then grabbed one of the students wrist and then guided (Student Name) out of the room, When (Teacher Name) was pulling the students wrist, (Student Name) was pulling back trying to get away from him. Student Statements Student Witness #1: (Student Name) was hitting and kicking and punching (Teacher Name). Mr. C grabbed him hy the shirt (shoulders) and walked him out of the room, Mr. C closed the door and locked (Student Name) out of the room. (Student Name) kept hitting and kicking Mr. C as they were walking out. Student Witness #2: (Student Name) was fighting the music teacher and hitting and cussing at him. Mr. C screamed at him to stop, but he wouldn't. Music teacher grabbed the student's wrist and pulled him out of the room. (Student Name) kept hitting and kicking him as they were walking out of the room. Mr. C locked (Student Name) out of the room. Student Witness #3: (Teacher Name) put (Student Name) in a chair. He grabbed (Student Name)’s hand because (Student Name) was trying to hit him. (Teacher Name) then pulled (Student Name) out of the chair by his hand. (Teacher Name) pulled (Student Name) by the shoulders to get him into the chair.