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CMS Student Incident Report
It is recommended BEFORE COMPLETING THIS FORM that you seek the help of a safe, trusted adult (teacher, parent, counselor) to support you first.
If you are not able to solve the incident by yourself and feel you now need the help of CMS Administration, this form will alert Mrs. Woodell and Mrs. Iyer. Please be thorough in your answers and descriptions below.
Thank you - GO BEARS!
Your First and Last Name
Your Grade Level
Date of Incident
Who was involved?
Names and Grade Levels (if known)
Who may be witness(es)?
If known, list first and last name(s) as well as grade level(s).
Location of Incident (check all that apply).
If the incident occurred in the classroom, state room number in "other."
Quad (by music rooms)
General Time of Incident (check all that apply):
During instructional time in the classroom
During instructional time outside the classroom
Please describe the incident honestly, completely, and accurately. Start from the beginning and describe the situation.
If you feel you made a mistake, please describe what that might be.
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This form was created inside of Cupertino Union School District.