THIS FORM HAS TWO PURPOSES:
1. To fill out an INCIDENT REPORT about an incident on campus. You can use this form to tell Admin about a potential conflict, lost or stolen items, something you saw, vandalism, your side of a story etc.
2. For students receiving an OFFICE REFERRAL to provide an incident report as part of the investigation and processing of behavior office referrals.
*This form is completely confidential. Only staff members will be able to see who is submitting them.
* THIS FORM IS ONLY MONITORED DURING SCHOOL HOURS.
* THIS FORM IS NOT FOR EMERGENCIES. Please immediately report emergencies to Lakeside staff.
Last Name, First Name
Who is your counselor?
Ms. Simmons- Last names A-H
Mrs. Adolfo-Cademartori- Last name I-Q
Mr. Rutherford- Last names R-Z
Pick a category to describe the incident.
Office Referral (Behavior Incident)
I have information related to an ongoing issue.
Something is missing or stolen. (Phone, Chromebook, other)
I am being Bullied or have witnessed bullying.
Names of all people involved.
Where did the event occur?
When did the event occur? What Period?
WHAT HAPPENED? (Give as much detail as possible.)
By typing and signing my name below, I declare the statements I have written are true.
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Valverde.edu.