If you are the person who suffered from the incident, then select Target. If you are reporting the incident, then select Reporter.
You are the: *
You are a(n): *
Your contact information/telephone number:
(Leave blank if you wish to remain anonymous).
Your answer
Which school or work site should receive this report?
School or work site: *
If the target is a student, please state which grade the student is in.
Grade:
Choose
Pre-K / EC
K
1
2
3
4
5
6
7
8
9
10
11
12
Name of the person(s) who were targeted.
Target(s): *
Your answer
Name of the person(s) who committed the alleged aggression.
Alleged Aggressor(s): *
Your answer
Date of incident: *
MM
/
DD
/
YYYY
Time of incident: *
Time
:
AM
PM
Location of incident (be as specific as possible): *
Your answer
List people who saw the incident - Bystanders.
Bystander (1):
Your answer
What is the role/position of the Bystander?
Position (1):
Clear selection
Bystander (2):
Your answer
Position (2):
Clear selection
Bystander (3):
Your answer
Position (3):
Clear selection
Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).
What happened? *
Your answer
Submit
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