Student Incident Report
Self-reported Student Incident Form
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What is your name?
What team are you on?
Date and Time of Incident
When did the most recent incident occur?
Is this a new issue or one that has been ongoing?
Where did this incident take place?
For example, "Hallway, near Mrs. XYZ's Homeroom", "Near the back of bus 47", etc.
Who else saw or heard what you did? Give first and last names, if you know them. If none, please answer "none"
Student(s) Being Reported
Statement of What Happened
Add as many details and names as possible
How did you learn about this information?
It happened to me
I saw it
Someone told me about it
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This form was created inside of Dallastown Area School District.