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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 Ms. Wang. Please be thorough in your answers and descriptions below.

Thank you - GO BEARS!
Your First and Last Name
Your answer
Your Grade Level
Date of Incident *
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, list classroom in "other."
General Time of Incident (check all that apply): *
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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