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Incident Reporting Form
Do not use this form if there is an immediate threat to Students, Staff, or Buildings, instead call 911.
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* Indicates required question
Contact Info: phone/e-mail/homeroom (optional)
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
Incident Date:
*
MM
/
DD
/
YYYY
Name of adult(s) you have already contacted (if any)
*
Your answer
Name(s) of accused (if known)
*
Your answer
Where did the incident happen:
*
Hallway
Classroom
Restroom
Gym
Playground
Lunch room
School Bus
Bus Stop
Cell phone
Social Media
Other:
Please check the item that best describes what the accused did. Please choose all that apply.
*
Physical; hitting, kicking, shoving, spitting, etc.
Teasing, name calling, put downs, criticizing, jokes.
Threatening in person, by phone, by e-mail, social media, etc.
Excluding or rejecting the student
Demanding money, homework, etc.
Getting another person to hit or harm the student.
Property issues (hiding, damaging, taking).
Making rude and/or threatening gestures.
Spreading harmful rumors or gossip.
Threatening physical harm to self
Weapon at school (gun, knife, etc.)
Threat against the school or staff
Other:
Required
Describe what happened. Use exact language and as much detail as possible.
*
Your answer
Is this report being made by a
Parent
Student
Other:
Clear selection
I agree that this information is accurate and to the best of my knowledge.
*
Yes
Submit
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