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Student Incident Report
This is a form for students to report behavior that is suspicious, or a building or personal safety concerns. Students may use this form to report incidents that they have experienced or witnessed. The Administration team will review reports and contact students as deemed necessary.
* Indicates required question
Email
*
Record my email address with my response
What is your role as a reporter?
I am the victim
I am a witness
I was informed of the incident
What is your team?
Choose
Team 6-0
Team 6-1
Team 7-0
Team 7-1
Team 7-2
Team 8-0
Team 8-1
Team 8-2
Describe the incident occurred.
Your answer
Type of incident
Verbal incident (repeatedly teasing, putting down, or insulting someone on purpose)
Emotional incident (gaslighting, blaming, invalidating, humiliation, guilt tripping)
Physical incident (hitting, kicking, or shoving someone)
Cyber incident (social media, email, text)
Social incident (getting others repeatedly to ignore or leave some out on purpose (isolation))
Vandalisim
Theft
Other:
Who was involved?
Your answer
Where did this happen?
Choose
Hallway
Bathroom
Locker room
Classroom
Stairwell
Bus
Social Media
Lunchroom
How often does this happen?
Choose
This is the first time
Once a week
Two or three times a week
Once a month
On going
When did this happen?
Choose
Before school (on campus)
Before school (off campus)
After school (on campus)
After school (off campus)
During Lunch
Passing Period
During Class
Are there any witnesses?
Your answer
Who did you report this to?
Your answer
Do you feel safe at school?
Yes
No
sometimes
Clear selection
What would you like to see be done?
Your answer
Optional: If you are comfortable, please write your name so we can follow up for more information.
Your answer
Submit
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