SMUSD Incident Reporting Form
Complete this form if you have credible information regarding a mistreatment incident and want to report it anonymously. This form is completely anonymous; formal disciplinary action may not be based solely on the basis of this report or an anonymous phone call. Please type or print clearly.

This report will be investigated in a timely manner. If you fear a student is in IMMEDIATE danger, contact the appropriate resource (i.e., the principal of the school, assistant principal) or CALL the Police at 911.
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Victim's Name / Person Harmed (Alleged) *
(Last, First)
Victim's School Site
Clear selection
Age
(Alleged Victim)
Grade
(Alleged Victim)
Gender
(Alleged Victim)
Perpetrator's Name / Person Who Hurt Someone (Alleged) *
(Last, First)
Alleged Perpetrator's School
Clear selection
Age
(Alleged Perpetrator's)
Grade
(Alleged Perpetrator's)
Gender
(Alleged Perpetrator's)
Where did the incident occur? *
Be specific (i.e., classroom, hallway, cafeteria, playground, bus).
Required
When did the incident occur? *
Time can be approximate.
MM
/
DD
/
YYYY
Time
:
What happened? *
Describe in detail.
Were there any witnesses? *
Names of witnesses.
Provide their name(s) and contact information.
List any evidence of mistreatment.
(i.e., letters, texts, photos, etc)
Was there a previous report filed by anyone regarding this incident? *
When was the previous report filed?
MM
/
DD
/
YYYY
Was there a police report filed? *
When was the police report filed?
MM
/
DD
/
YYYY
Have you been mistreated or witnessed mistreatment by this person before? *
If so, how many times?
Was a report filed for the previous time(s)?
When was the report filed?
MM
/
DD
/
YYYY
Email Address (to receive a copy of this submission)
Submit
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