High School Incident Report

High School Incident Report
Please complete this form to the best of your knowledge so we can assist you.

The information will be kept confidential with your campus administrator and/or superintendent.
Date of Incident*

MonthDayYear
Date
Date of Report

MonthDayYear
Date
Hour MinutesAM/PM Option
Who was the person(s) engaged in the incident?
Grade of the person(s) who engaged in bullying?
Grade of the person who was being bullied?
What type of bullying?

PhysicalEmotional/SocialDamage to PropertyOnlineOther
Where did the incident take place?

After School ProgramBusBus StopCell PhoneClassroomHallwayGymInternetLocker RoomLunch RoomParking LotPlaygroundRestroomSchool Sponsored EventOther
Other Location Details (please explain the specific details such as which hallway, where in the internet, what restroom, etc.)
Person reporting the incident (optional)

First NameLast Name
May we contact you for more information?*

YesNo
Email Address (optional)
example@example.com
Phone Number (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: