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.
First Name
Last Name
Email
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. *
School *
I am a *
Required
What was the nature of the incident? Select all that you believe apply *
Required
Location *
Time *
Time
:
Date *
MM
/
DD
/
YYYY
Did you initially make a report of this incident to an adult at the school site? *
If yes, please provide the name of the individual, although not required.
Do you feel the response was sufficient?
Clear selection
Were you on the receiving end of this incident?
Clear selection
Did you witness the incident occurring with another person?
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.
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