Confidential Incident Reporting Form

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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.

Please be advised that there will be a delay in response to reports received in July 2022, as staff is out of the office and may not have consistent access. If you need immediate assistance and are in a CVUSD summer program, the program administration can be contacted directly to assist in this matter. Otherwise, we look forward to connecting with you soon. Thank you.

First Name

Last Name

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

School *

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 *

Time *

Time

Date *

YYYY

Did you initially make a report of this incident to an adult at the school site? *

Yes

If yes, please provide the name of the individual, although not required.

Do you feel the response was sufficient?

Yes

Clear selection

Were you on the receiving end of this incident?

Yes

Clear selection

Did you witness the incident occurring with another person?

Yes

Clear selection

Please provide the first and last name(s) of any other individuals involved in this incident if you know the name(s).

Please provide any other information you feel is important.

Submit

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