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Incident Reporting Form
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* Indicates required question
Name of person reporting the incident:
optional
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Location of incident
*
Primary School
Elementary School
Middle School
High School
School Bus
How did you find out about the incident?
Your answer
Where specifically did the incident take place?
i.e. in the locker room, specific classroom, in the community, etc.)
Your answer
Who else may have witnessed the incident?
Your answer
Severity of the incident
*
Slight issue
1
2
3
4
5
6
7
8
9
10
Extremely severe issue
Names of individuals involved
Your answer
Description of incident
please be as specific as possible
Your answer
Suggested resolution for all parties involved.
Your answer
Would you like to be contacted regarding this issue?
Yes
No
Clear selection
If you would like to be contacted please provide contact information.
Your answer
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