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ER9 Safe School Climate Anonymous Incident Report Form
All anonymous complaints will be reviewed. However, please note that no disciplinary action shall be taken solely on the basis of an anonymous complaint.
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* Indicates required question
Name (optional)
Your answer
Email Address (optional)
Your answer
Who is making this report?
*
Parent/Guardian
Teacher/Staff Member
Student
Other:
The name of the student who was committing the act that you are reporting:
*
Your answer
Date, Time, and Place of the mean behavior:
*
Your answer
Description of the incident:
*
Your answer
Name(s) of witness(es):
Your answer
Any additional information that you think will help us to better understand the incident:
Your answer
Select the School Climate Specialist who will be responding to this incident:
*
Ms. Kathy Burke, Helen Keller Middle School
Mr. Christopher Basta, Redding Elementary School
Mr. Michael Brownstein, Samuel Staples Elementary School
Ms. Darlene Wallin, John Read Middle School
Ms. Jennifer Desmarais, Joel Barlow H.S./ER9 SSC Coordinator
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