WFMS Student Reporting Form
This form may be used to report any issues that you are having as a student. You can also report issues that other students are having by using this form. We will use the information that you provide in the most confidential way possible. We may call you in to discuss the incident or issue in more detail if needed. (IF THIS IS AN EMERGENCY OR IF SOMEONE IS IN DANGER, GO DIRECTLY TO AN ADULT AND ASK FOR HELP.)
Today's Date
Date
MM
/
DD
/
YYYY
Your First Name
Your answer
Your Last Name
Your answer
Your Lunch Number
Your answer
Select Gender
Select Grade
Who are you making this statement about?
Your answer
Date the incident took place or started.
Date
MM
/
DD
/
YYYY
Where did the incident or problem occur?
Required
Please list any witnesses to the event.
Your answer
Was there an adult present? If so, please type their name(s).
Your answer
Did you report the incident to an adult?
If you did report the incident to an adult, who did you report it to? (if you didn't report it, type in "I did not report."
Your answer
Type a description of the incident or problem. Use as many details as possible.
Your answer
Has this ever happened before? If so, explain.
Your answer
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