GSMS Student Incident Report Form
This form is to help us gather information, investigate, and take the appropriate action in maintaining a safe learning environment for all of our students.
Step #1 Give us more information about you.
First Name *
Your answer
Last Name *
Your answer
Grade *
Step #2 Tell us about what happened.
Who is the person you are reporting?
First Name *
Your answer
Last Name
Your answer
Grade *
Are there other students involved or responsible for what happened?
If "YES", then who are they?
First Name
Your answer
Last Name
Your answer
Grade
Date of the incident? *
MM
/
DD
/
YYYY
Approximate time the incident occurred? *
Time
:
List any witnesses.
Your answer
Describe the incident in detail. What happened? What did you see? What did you hear? *
Your answer
Step #3 Past experiences with this student or person:
Have you had any problems with this person in the past? *
If "YES", when or how long ago did this past incident occur?
MM
/
DD
/
YYYY
Was this incident reported?
Who did you report this incident to?
Your answer
Describe the past incident.
Your answer
LAST STEP, Your contact information:
How may we contact you?
Phone #
Your answer
Email:
Your answer
If you are reporting this incident for someone else, what is your name?
First Name
Your answer
Last Name:
Your answer
Submit
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