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Incident Report
If you know of something important that occurred to you or another student, you may report it with this form. These incidents are confidential and there is no guarantee that you will be notified of any action taken. Thank you for helping support a positive environment in our school.
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* Indicates required question
Where did the incident occur?
*
Choose
At an after school activity
At the bus stop
During recess
In a text message
In an email
In an instant message
In class
In front of the school
In the bathroom
In the cafeteria
In the hallway
In the parking lot
On Facebook
On the bus
On the field
On Twitter
On YouTube
Over the phone or on a voicemail
Other
When did it happen?
*
MM
/
DD
/
YYYY
What time did it happen?
Approximate time okay.
Time
:
AM
PM
How many times has this situation happened?
*
Choose
This is the first time
One other time
Once a month
Once a week
Every day
Have you reported this incident to an adult at school?
*
Yes
No
Who was bullying. harassing, intimidating or causing harm?
*
Include first name, last name and grade if known.
Your answer
Who was the person being harmed, bullied, harassed or intimidated?
*
Your answer
Describe what happened. Give as much information as you can. Let us know if there were any witnesses.
*
Your answer
Who are you?
*
Choose
Student
Teacher
Staff Member
Administrator
Board Member
Volunteer
Parent
Other
What is your name? (Optional - Not Required)
Your answer
Submit
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