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Anonymous Incident Report
Please fill out this form. Your answers will remain anonymous (nobody will know you submitted this).
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* Indicates required question
Today's Date
*
MM
/
DD
/
YYYY
What time is it?
*
Time
:
AM
PM
Your name (OPTIONAL--You don't have to answer this)
Your answer
Which of the following best describes you?
*
Student target
Student (witness)
Parent/Guardian
Staff Member
Other:
What was your involvement in the incident?
*
I was directly involved
I observed the incident
I heard about the incident
Target Student
Name of Target
*
Your answer
Grade of Target (optional)
6
7
8
Clear selection
Incident Description
Where did this incident take place?
*
Your answer
Names of people involved and their role (Witness, victim, or participant) Example: Mickey Mouse- Witness, Donald Duck - Victim
*
Your answer
Description of Incident
*
Your answer
Were there any adults in the area when this happened? Please indicate the name of the Adult (if you know)
Your answer
Name(s) of others who may have witnessed the incident:
Your answer
Is this a recurring situation?
*
Yes
No
Unknown
Phone number or email you can be reached (OPTIONAL)
Your answer
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