Incident Report

Name (Please be advised that remaining anonymous may prevent further action from being taken such as reporting to police or prosecution.)

First Name Last Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Date of Incident *

Date

Nature of Incident *

Bullying Graffiti Verbal Physical Online interaction Other

Location of Incident (be specific) *

Do you have any documentary evidence of the incident? *

Yes No

Can you describe the offending individual(s)? *

Yes No

Please describe the incident and offending individual(s) *

I am reporting this because: *

For the purposes of data collection I want help resolving this issue I want help understanding my rights Other

Would you like to be contacted by our Security Director? *

Yes No

Has the incident been reported anywhere else?

Yes No

Where was it reported? Please provide contact information if available.

What action has been taken, if any?

Please upload any photos or other files related to the incident you are reporting.

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