Confidential Incident Report
Stafford County Public Schools, as well as North Stafford High School, are committed to ensuring that both students and Staffulty spend their school day in a safe and healthy environment. To that end, the School Board has instituted policies in response to drugs, weapons, and student violence in our schools.

Please help us in our mission to make North Stafford High School a safe learning environment for everyone by using this confidential form to report any concerns, incidents, or potential incidents of violence (including harm to self or others), bullying, sexual harassment, drugs, and/or weapons.

Responses in this form are forwarded directly to our high school's Counseling Director who will then consult with our Administration and Counseling Center teams. Together, we will make every effort to protect your identity and the confidentiality of this form; however, we may need to contact you for further information during the course of this investigation.

Please note that if this form is submitted after school hours, it will be reviewed the next school day.

Your First Name *
Please include your full first name.
Your answer
Your Last Name *
Please include your full last name.
Your answer
Your E-mail Address *
Please provide a valid e-mail address. This will allow our Staffulty to follow-up with you after reviewing your submission.
Your answer
Your Phone Number *
Please provide a valid phone number. This will allow our Staffulty to follow-up with you after reviewing your submission.
Your answer
Your school affiliation with our high school *
Date and Time of Incident *
If an exact date and/or time is not known, please use an approximate date and/or time.
MM
/
DD
/
YYYY
Time
:
Location of Incident *
Please provide the best description of the location using specific information, if possible.
Your answer
Person(s) Directly Involved in the Incident *
Please provide the name(s) of any person(s) involved in this incident. Be specific as possible and provide full first and last name(s).
Your answer
Witness(es) to the Incident (if any)
Please provide the full first and last name(s) of any witness(es) to this incident.
Your answer
Description of Incident *
Please be as specific as possible. Remember to add any and all details below.
Your answer
I acknowledge that I have reviewed, read, and understood the field required above. I certify that all of the answers provided are accurate and complete to the best of my knowledge. I understand that any intentional inaccuracies of the details provided above may subject me to appropriate discipline matters. I allow North Stafford High School to disclose this information with all appropriate personnel and agencies as they see fit to assist in this investigation. *
Required
Submit
Never submit passwords through Google Forms.
This form was created inside of Stafford County Public Schools.