Because You Care Form
Please fill out the below with as much information as possible. You are always encouraged to discuss any student concerns with the Administration, Teachers, Counselors, or School Resource Officer. Please feel free to contact us at 815-844-6113.
What type of student concern are you reporting?
Check all that apply -
Name(s) of person(s) of whom you are concerned. *
Your answer
Please describe your concerns. If a specific incident has occurred, please describe the incident in detail.
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Room/Location of Incident
Your answer
Name(s) of person(s) that may be doing the bullying/harassing, or contributing to the concerns mentioned above.
Your answer
Name(s) of person(s) who witnessed incident or share concerns.
Your answer
Inappropriate behaviors observed:
Check all that apply.
Behavioral/Social/Emotional Concerns
Check all that apply.
Physical evidence available
Check all that apply.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms