HMS Incident Reporting Form
Complete this form if you have credible information regarding a mistreatment incident and want to report it
anonymously. This form is completely anonymous; formal disciplinary action may not be based solely on the basis of this report or an anonymous phone call. Please type or print clearly.

This report will be investigated in a timely manner. If you fear a student is in IMMEDIATE danger,
contact the appropriate resource i.e., the principal of the school, assistant principal, or police.

Victim's Name (Alleged)
(Last, First)
Your answer
Age
(Alleged Victim)
Grade
(Alleged Victim)
Gender
(Alleged Victim)
Perpetrator's Name (Alleged)
(Last, First)
Your answer
Age
(Alleged Perpetrator's)
Grade
(Alleged Perpetrator's)
Gender
(Alleged Perpetrator's)
Where did the incident occur?
Be specific (i.e., classroom, hallway, cafeteria, playground, bus).
When did the incident occur?
Time can be approximate.
MM
/
DD
/
YYYY
Time
:
What happened?
Describe in detail.
Your answer
Where there any witnesses?
Names of witnesses.
Provide their name(s) and contact information.
Your answer
List any evidence of mistreatment.
(i.e., letters, texts, photos, etc)
Your answer
Was there a previous report filed by anyone regarding this incident?
When was the previous report filed?
MM
/
DD
/
YYYY
Was there a police report filed?
When was the police report filed?
MM
/
DD
/
YYYY
Have you been mistreated or witnessed mistreatment by this person before?
If so, how many times?
Was a report filed for the previous time(s)?
When was the report filed?
MM
/
DD
/
YYYY
Email Address
Your answer
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