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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