Confidential Incident Reporting Form
Prior to completing this form, CVUSD does encourage you consider reporting any incidents of harassment, intimidation, bullying or discrimination to the school site principal. However, we recognize that for some students and families, that may not feel safe or have attempted and the outcome felt incomplete or insufficient. Therefore, we created this central reporting option because CVUSD takes seriously any incidents of bullying, discrimination, harassment, intimidation and racism. Please complete this form to report an incident that occurred that you were either directly involved in or you directly observed. When conducting an investigation of this report we will keep your name confidential to the extent possible. If you wish to submit a form anonymously please leave Name and Email sections blank. Please note email is not required but necessary in order to make contact with you.
* Required
First Name
Your answer
Last Name
Your answer
Email
Your answer
In order for CVUSD to follow-up, are you in agreement to have a Student Support Services staff member call or email you for additional information? If yes, please provide your contact information above.
*
Yes
No
School
*
Choose
Acacia Magnet School
Aspen Elementary
Banyan Elementary
Century Academy
Colina Middle School
Conejo Elementary
Conejo Valley High School
Conejo Valley Independent Study
Cypress Elementary
EARTHS Magnet School
Glenwood Elementary
Ladera STARS Academy
Lang Ranch Elementary
Los Cerritos Middle School
Madrona Elementary
Maple Elementary
Newbury Park High School
Open Classroom Leadership Magnet
Redwood Middle School
Sequoia Middle School
SHINE
Sycamore Canyon (TK-5)
Sycamore Canyon (6-8)
Thousand Oaks High School
Walnut Elementary
Weathersfield Elementary
Westlake Elementary
Westlake High School
Westlake Hills Elementary
Wildwood Elementary
I am a
*
Student
Parent/ Guardian
Staff member
Other family member
Other:
Required
What was the nature of the incident? Select all that you believe apply
*
Bullying
Harassment
Discrimination
Intimidation
Racism
Other:
Required
Location
*
Your answer
Time
*
Time
:
AM
PM
Date
*
MM
/
DD
/
YYYY
Did you initially make a report of this incident to an adult at the school site?
*
Yes
No
If yes, please provide the name of the individual, although not required.
Your answer
Do you feel the response was sufficient?
Yes
No
Clear selection
Were you on the receiving end of this incident?
Yes
No
Clear selection
Did you witness the incident occurring with another person?
Yes
No
Clear selection
Please provide the first and last name(s) of any other individuals involved in this incident if you know the name(s).
Your answer
Please provide any other information you feel is important.
Your answer
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