Strasburg School District 31J - Form B
Hemphill Middle School 2025 - 2026 
WRITTEN STATEMENT This form is completed by Target/Accused/Witness
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Basic Information
First and Last Name *
Grade *
Incident Type:
This statement is in regard to something that happened to: *
Required
Who was involved?
NAME(S) of person(s) Involved in the Incident and their GRADE(S) *
Incident Details
When did the incident take place? *
Where did the incident take place? *
Describe the incident. Provide as many details as possible. Who, what where, when how, and whether witnesses were present. *
Name(s) of Person(s) with Knowledge of the Incident including Grade(s) *
Have you attempted to discuss your concern with any school/district personnel? *
If yes, which staff member have you talked to? Include Name(s), when you talked to them, and what the result was.
What outcome would you like to see for this situation *
Electronic Signature
By checking the box below, I confirm this information is accurate to the best of my knowledge.
Check the box as your signature *
Required
Please Type your First and Last name to confirm your signature *
Submit
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