Student/School Concern Reporting Form
This is a place for you to communicate concerns you have regarding the safety of yourself and others OR other concerns you don't feel comfortable talking with someone about face-to-face. Please know that these all will be read as soon as we are notified you have submitted the form. We will do our best to address the concern as quickly as possible. If you leave your name, we will follow up with you with any details we can. If you don't leave your name, that is fine but please trust us that we will work to address the problem. ***NOTE- IF YOU ARE REPORTING AN EMERGENCY OUTSIDE OF SCHOOL HOURS, PLEASE CALL 911 IN ADDITION TO THIS REPORT!
Is this a high school, middle school or both schools concern?
Both Schools or whole district
Your Name (if desired, not required)
Description of problem or incident (including names of those involved)
Date of incident (approximately, if known)
Time of incident (approximately, if known)
Location of incident
Do you feel you need to speak with a counselor or social worker?
Is there any other information you want to provide us so that we know how best to help you/address your concern OR are there any other needs you have that we can help address?
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This form was created inside of Heath City Schools.