GVJH Confidential Report form
Date of the incident
MM
/
DD
/
YYYY
Time of the incident
Time
:
Where did the incident take place?
Who is the victim?
(The victim is the person who is being teased, harassed, bullied, intimidated, and/or threatened). *Please give the person's First and Last name plus their grade. Do not worry about spelling the name correctly. If you do not know the name please give as much information as possible: grade, male/female, physical description.
Your answer
Witness(es)
If there was a person or persons who witnessed this please write their First and Last name plus their grade. Do not worry about spelling their name correctly. If there was not a witness write -- NONE.
Your answer
What happened?
Describe what happened. It is very important that you give as much detail as possible. We can not help you if we don't know what happened.
Your answer
Please indicate who you are.
What is your name (optional)
Providing your name is optional, but the information is important to us if we have questions. Your identity will be kept confidential. Please give your First and Last name.
Your answer
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