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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 Assistant Principal Mrs. Iyer. Please be thorough in your answers and descriptions below.
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* Required
Your First and Last Name
Your answer
Your Grade Level
6th
7th
8th
Clear selection
Date of Incident
*
MM
/
DD
/
YYYY
Who was involved?
*
Names and Grade Levels (if known)
Your answer
Who may be witness(es)?
If known, list first and last name(s) as well as grade level(s).
Your answer
Location of Incident (check all that apply).
*
If the incident occurred in the classroom, state room number in "other."
Online
Core (ELA/SS)
Math
Science
PE
Electives
Blacktop
Field
Quad (by music rooms)
New Quad
Library
Hallways/Corridors
Cafeteria
Other:
Required
General Time of Incident (check all that apply):
*
During instructional time in the classroom
During instructional time outside the classroom
Brunch
Lunch
Before School
After School
Other:
Required
Please describe the incident honestly, completely, and accurately. Start from the beginning and describe the situation.
*
Your answer
If you feel you made a mistake, please describe what that might be.
Your answer
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