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* Indicates required question
Step 1: Contact Information
Optional - You may skip to step 2
First Name
Your answer
Last Name
Your answer
Telephone
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Email
Your answer
Step 2: Victim Type
Crime is Against
*
Student
Staff Member
Facility
Required
Specific Type
*
Assault
Gang Activity
Drugs
Abuse/Bullying
Harassment
Gun in School
Knife in School
Other:
Required
Step 3: Date and Location of the Incident
This Event
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Will occur in the future
Occurred in the past
Date
MM
/
DD
/
YYYY
Time
Time
:
AM
PM
Which School
Danforth Elementary
Gilman Elementary
Iroquois West Upper Elementary
Iroquois West Middle School
Iroquois West High School
Clear selection
Location in School?
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Step 4: Who was Involved
Suspect:
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Victim
Your answer
Please provide a short description of the incident.
*
Your answer
May we contact you for additional information?
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