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Incident Report Form
Do not use the form if there is an immediate threat to staff, students, or the building. Call 911.
* Indicates required question
Email
*
Record my email address with my response
Contact Information (Name, Phone number, email)
Your answer
Today's Date
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MM
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DD
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YYYY
Incident Date
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MM
/
DD
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YYYY
Name of adults you have already contacted.
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Your answer
Names of the accused (if known).
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Your answer
Where did the incident take place?
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Hallway
Classroom
Restroom
Gym
Playground
Lunchroom
School Bus
Bus Stop
Cell Phone
Social Media
Other:
Please check the item that best describes what the accused did (choose all that apply)
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Physical: hitting, kicking, shoving, spitting etc.
Teasing, name calling, put down , critizing, jokes
Threating in person, by phone, email. social media
Excluding or rejecting student
Demanding money, homework
Getting another student to hit or harm student
Property issues( Hiding damaging, taking)
Making Rude or threating comments
Threating physical harm or self harm
Weapon at school (gun, knife etc)
Threat against the school staff
Other:
Required
Describe what happened. Use exact language and as much detail as possible.
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Your answer
Is this report being made by
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Parent
Student
Other:
I agree this information is accurate to the best of my knowledge.
*
Agree
Required
Submit
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