Confidential Reporting Form

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USD 220 takes the safety of our students and staff very seriously. Early reporting can often prevent crisis for one or more individuals. This allows us to intervein and be proactive. This form may be submitted by any concerned person, adult or child, and will notify administration immediately upon submission.

This form is a secure location to report any type concern you may have about a USD 220 student, staff member or facility. It is not anonymous, as all tips are fully investigated meaning follow up with the reporter may be necessary; however, it is confidential and secured. The report need not fear that their name or personal information will be shared with anyone other than law enforcement, and only then as required.

When to fill out the form:

*If you suspect someone is in danger (harm to themselves or others).

*If you overhear or see something you are cautious of or something that causes you concern.

*If you or someone else is being bullied and afraid to report it due to repercussions.

*If you or someone else is experiencing abuse or trauma in any environment.

*If there is something unsafe about an environment or facility issue that could potentially be harmful.

When NOT to fill it out:

*If someone is in IMMEDIATE danger - find the nearest adult, call the office and ask for an administrator, or notify the Clark County Sheriff's department.

*If you need to complain about an item or incident - please contact the administrator for that building.

REMEMBER: It is always better to report something and be wrong, than to have something go wrong that could have been prevented. Reports made in good faith that are mistakenly wrong are protected; however, the district reserves the right to discipline persons who make bad faith, knowingly false, or vexatious complaints, reports or inquiries or who otherwise abuse this reporting form.

Reports will be fully investigated as soon as possible and provide intervention/help within our ability ASAP. THANK YOU for helping to keep our Bluejay community a safe and happy place to be for all students.

*Note: All USD 220 employees are mandated reporters. USD 220 works in full cooperation with law enforcement.

Nature of Report: *

Suicide or Self-Harm (yourself or someone else)

Bullying (verbal, physical, cyber)

Other Safety Concern (facilities, staff, student)

Other:

Required

Concern is about: *

Myself

Elementary Student

Junior High School Student

High School Student

A USD 220 Staff Member

USD 220 Facility

Other:

Required

How did you become aware of this situation? (Check as many as apply) *

It is about myself

I heard something

I saw something

Someone else told me about it

Other:

Required

What day and time did you become aware of this? *

Did you report this to anyone else? *

A teacher

A different USD 220 staff member

An administrator

A coach

A parent or trusted adult outside of school

Provide as much specific information you can about the concern including names of those involved. *

What is the best way to contact you if we need to follow up with you directly? *

cell phone

in person

Required

Please list your contact information here (email, phone, or best time to find you in person) *

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