MSC Incident Report Form

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Use this form to report issues relating to bullying, cyber-bullying, harassment, or any other issue that might endanger a member of the school community.

You may want to consider meeting with a trusted adult or your school counselor to complete this form and remain anonymous.

Your Name (Optional but helpful)

I am a *

Student

Family Member

Other:

Describe what happened:

Name of Alleged Aggressor or person causing concern *

Name of Alleged Victim/person being targeted (if applicable) *

Names of Witnesses/Bystanders

Location of incident *

Date Incident Occurred (or timeframe) *

Time Incident Occurred (class period, approximation) *

Have you observed previous issues with this particular student? If yes describe *

Please describe the current situation with as much detail that will help the person investigating the situation. *

What help would you like with this issue? *

Additional Information

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