Incident Report

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Incident Report

In addition to, or instead of completing this form, students may contact a member of the mental health team, or your principal or other trusted adult on campus for advice and support.

Do you wish to remain anonymous? *

Yes

Were you involved in the incident? *

Yes

If you were not involved, when did you hear/learn about the incident? *

YYYY

Name of the Respondent(s) (person/people whose behavior is the subject of this report) *

Grade level and/or building the respondent is in. *

Parent/Caregiver

Required

Date of the incident

YYYY

Time of the incident *

Time

Location of the incident (on campus or off campus at a school function (i.e. game, field trip etc.) *

Other witnesses to the incident (teachers, adults, other students, etc) *

Have you or anyone else reported this incident to another adult? *

Yes

If you have reported the incident, who did you report it to? *

Incident involved (check all that apply) *

Intimidation or abuse but no verbal threat or physical contact

Verbal threats but no physical contact

Physical contact but no verbal threat

Both a verbal threat and physical contact

Only students

Students and adults

sexual

harassment

written (email from a school account, letter or note, etc)

discrimination

damage to property

hazing

stalking

written graffiti/slur

disruption to the community

other

Required

Basis of incident (Why do you believe this incident occurred?) Check all that apply *

Ancestry/National origin

Color

Weight

Disability

Sex/Gender

Gender Identity or Gender Expression

Socioeconomic Status

Race/Ethnicity

Religion

Sexual Orientation

Political Views or Affiliation

Other

Not Sure

Required

Description of the incident (Please provide as much detail as possible) *

Have there been any changes in the victim's behavior? Check all that apply.

Attendance

Antisocial behaviors

Social interactions

Grades

Self-destructive behaviors

Depression

Feelings about self/others

Withdrawal

Other:

This chart shows the steps that will be taken to address the incident once a report is filed.

You may provide your name and request that it be held in confidence as the inquiry goes forward. If you request that your identity remain confidential, the person handling the inquiry will do so to the extent practicable and permitted by NCSD policy and applicable laws. Our ability to investigate allegations of misconduct and to take corrective action may be impeded if your identity is not provided to the person responding to the complaint. Depending on the nature of the allegations(s) raised (e.g. unlawful discrimination or sexual violence), conducting a fair and complete investigation may require that the full details of the incident, including your identity be shared.

Name

Submit

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