Safety Concern Report
School or Site Name *
Where did the incident occur? *
What time did it happen?
Time
:
How many times has this happened? *
Has this been reported to an adult? *
Who was being harmed, bullied, harassed or intimidated?
Your answer
Who was bullying, harassing, intimidating or causing harm?
Include first name, last name and grade if known
Your answer
Describe what happened. Give as much information as you can. Let us know if there were any witnesses. *
Your answer
What is your role? *
What is your name? (Optional)
(You DO NOT have to give your name if you wish to remain anonymous. However, if you would like for someone to make contact with you directly, you will need to provide some kind of contact information.)
Your answer
If you are not a student at this campus and would like someone to contact you, please add your phone number here. (Optional)
Your answer
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