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
Person reporting the incident
Date of Incident
Please record the date and time that the incident occurred.
Who else have you talked to about the incident?
Another adult at school (if selected list name in other below)
Have not spoken with anyone
Where did the incident occur?
Location (check all that apply)
To and from school (walking, riding, bike, etc.)
Playground/athletic fields (during lunch/recess)
After School Activity
Community (local park, store, etc.)
Electronically (online or cell phone)
What best describes the incident?
Check all that apply
Child Abuse (physical, emotional, neglect, etc)
Inappropriate use of social media
Physical Violence (fighting)
Religious, racial, gender, or ethnic remarks
Social Exclusion (isolation)
Spreading False Rumors
Threats (self-harm or threat to others)
Truancy (student not in school)
Describe in detail what you would like to report. Please explain it clearly by telling exactly what you saw or heard.
Names individuals directly involved in the incident.
Names anyone else who witnessed what happened.
If you would like to be contacted please enter your contact information below.
Email, Phone, Meeting, etc.
I understand that a false report will be subject to a discipline referral and will be referred to the school administrator. I agree that all of the information is accurate and true to the best of my knowledge.
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This form was created inside of Falls Church City Public Schools.