INCIDENT REPORT

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INCIDENT REPORT

THIS FORM HAS TWO PURPOSES:

1. To fill out an INCIDENT REPORT about an incident on campus. You can use this form to tell Admin about a potential conflict, lost or stolen items, something you saw, vandalism, your side of a story etc.

2. For students receiving an OFFICE REFERRAL to provide an incident report as part of the investigation and processing of behavior office referrals.

*This form is completely confidential. Only staff members will be able to see who is submitting them.
* THIS FORM IS ONLY MONITORED DURING SCHOOL HOURS.
* THIS FORM IS NOT FOR EMERGENCIES. Please immediately report emergencies to Lakeside staff.

Email *

Date? *

YYYY

Last Name, First Name *

ID# *

GRADE *

7th

8th

Who is your counselor? *

Ms. Simmons- Last names A-H

Mrs. Adolfo-Cademartori- Last name I-Q

Mr. Rutherford- Last names R-Z

Pick a category to describe the incident. *

Office Referral (Behavior Incident)

Student/student conflict

I have information related to an ongoing issue.

Student/Teacher conflict

Something is missing or stolen. (Phone, Chromebook, other)

I am being Bullied or have witnessed bullying.

Names of all people involved. *

Where did the event occur? *

When did the event occur? What Period? *

WHAT HAPPENED? (Give as much detail as possible.) *

By typing and signing my name below, I declare the statements I have written are true. *

Submit

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