MEH Incident Report Form
This form may be used by any student or adult to report incidents of concern. Your name will be kept confidential (if you choose to list your name below). We may follow up with you if we need more information. Please understand that anonymous reports often limit our investigation, and the more information you can provide can help our counseling department and administration address the incident. Incidents may include teasing, gossip/rumors, social exclusion, physical violence, threats, etc. If you fear that a student is in immediate danger, please contact the main office at 703-720-5700.
Your Name (person reporting the incident)
Last Name, First Name
Your answer
Person reporting the incident *
Required
Date of Incident *
Please record the date and time that the incident occurred.
MM
/
DD
/
YYYY
Time
:
Who else have you talked to about the incident? *
Required
Where did the incident occur? *
Location (check all that apply)
Required
What best describes the incident? *
Check all that apply
Required
Describe in detail what you would like to report. Please explain it clearly by telling exactly what you saw or heard. *
Your answer
Names individuals directly involved in the incident. *
Your answer
Names anyone else who witnessed what happened. *
Your answer
If you would like to be contacted please enter your contact information below.
Email, Phone, Meeting, etc.
Your answer
*
Required
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