Genoa-Kingston CUSD 424 Online Threat/Concern Report Form

1

What type of threat is this?

Self Harm

Threat Against Others/Property

Concerning Post/Incident

2

What is the name and grade of the person who is making the threat of self-harm? If you do not know their name, please list as many identifying facts as you know.

3

What is the nature of the threat?

4

When was the threat made ?

5

When were you made aware of the threat?

6

How was the threat communicated?

In Person

Social Media

Texting

Other

7

What is the account username & social media platform that is a threat/concern:

8

Has this person made threats of self harm in the past?

Yes

No

9

Does this person have access to weapons?

Yes

No

Unsure

10

What is the name and grade of the person who is making the threat? If you do not know their name, please list as many identifying facts as you know.

11

Who/What is the target of this threat? If you do not know their name, please list as many identifying facts as you know.

12

What is the person threatening to do? Please list all details that are known.

13

When was the threat made?

14

When were you made aware of the threat?

15

How was the threat communicated?

In Person

Social Media

Texting

Other

16

Has this person made any similar threats in the past? If so, please include details here:

17

Additional InformationIs there anything else we need to know about this threat that was not specifically asked?

18

please upload any images pertinent to the threat:

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

19

Which school does the threat pertain to* This field is required.

High School

Middle School

Genoa Elementary School

Kingston Elementary School