Tetzlaff Trojan Traits Incident Report

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ABC Unified School District: Child Welfare and Attendance
Witness to Incident Report

Please complete this form to report safety concerns here. YOUR NAME WILL NEVER BE USED WHEN REPORTING AND INVESTIGATING AN INCIDENT. Thank you for keeping Tetzlaff a safe and welcoming environment.

Email *

Date *

YYYY

Time *

Time

Location of Incident *

Last Name *

First Name *

ID Number *

Please provide a description of the incident: *

I have personal knowledge of the facts set forth in this declaration, and if necessary, I am capable and competent to testify to those facts. Provide a detailed description of the event below. (Please provide the details, who was involved, where did it occur, what happened, when did the incident occur and why the incident occurred?)

Testimony (optional)

I do not wish to testify at any hearing concerning the above described incident or have my identity as a witness disclosed because I feel that it would subject me to an unreasonable risk of psychological or physical harm for the following reason:

Acknowledgement: Print First and Last Name *

Please Read: I have read the foregoing statement and declare under penalty of perjury that it is true and correct. Printing your first and last name is agreeing to the preceding statement.

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