Anonymous Incident Report Form
This is a district-wide form used at Elmwood Community Schools to report (anonymously or non-anonymously) any kind of bullying, cyber-bullying, or harassment.
Last Name of Person Reporting Incident (Optional)
Your answer
First Name of Person Reporting Incident (Optional)
Your answer
Name of Victim(s) *
Your answer
Name of Student(s) Bullying *
Your answer
Name of Witnesses to Incident (If Any)
Your answer
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Location of Incident (Select All That Apply) *
Required
Type of Bullying (Select All That Apply) *
Required
Bullying Behaviors Observed (Select All That Apply) *
Required
Did the incident result in any injuries? *
If yes to the question above, was the incident reported to the school nurse and building principal? *
Incident Was Reported to the Following School Personnel (Check All That Apply) *
Required
Was the incident reported to the police? *
Describe the Incident (Please use as many details as possible): *
Your answer
Is there physical evidence related to the incident? *
If you marked yes above, please select any kinds of evidence that apply below:
Submit
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