St. Teresa of Calcutta Incident Reporting Form

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Please complete this form to report any incident you have seen or heard about or any incident that may be happening to you.

Name (Please include your name, if you can, in case we need more information about this issue. If we do not know your name, we may not be able to address the issue completely.)

Grade (optional - you may skip this)

Clear selection

Is this an incident you have seen, heard about, or is happening to you? (choose all that apply) *

I've seen this happen.

I've heard about this happening.

This is happening to me.

Required

Is this the first time this has happened? *

Yes

It's the first time I've seen it happen but it may have happened before.

If this is not the first time this has happened, please explain how many other times this may have already happened.

Please describe the incident you saw or heard about or that is happening to you. *

Please include the name(s) of the person(s) actively involved in the incident *

Please include the name(s) of the person(s) affected by the incident. *

Where did this incident happen? *

You can choose more than one location or add one if you need to. Please be very specific.

If this incident happened in school, please be specific about where in school this is happening.

On what date did this incident happen? *

YYYY

What time of day did this incident happen? *

You can say morning, afternoon, or evening if you don't know the exact time.

Have you seen this incident occur more than once? If yes, please explain. Please try and be as specific as you can. *

You can say something like "I've seen this incident happen three times already" or you can say "I've seen this incident happen Monday, Tuesday ad Wednesday of this week."

Please name anyone you think may have also seen this incident happen or who may have stepped in to help. *

This is to help us talk with anyone else who may have also seen the situation happen.

If you feel comfortable, please let us know how to contact you if we need more information or need to reach out to you to help.

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