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? *
Where did the incident occur? *
Location (check all that apply)
What best describes the incident? *
Check all that apply
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.
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