Spanish (Latin America)
CHS Incident Report
This form allows you to report an incident between yourself and a student, a staff member, or an incident that you have witnessed. The form will ask you to provide details of what occurred. once it is turned in actions will be taken to further address the incident with the student, or staff member. Please note that all information shared below will be kept as private as possible unless it may affect health and/or immediate safety. All questions have been written and reviewed with student imput.
Email (Optional, but useful for follow-up and if you want a copy of your responses)
Discrimination (specify below)
Field trip(specify below)
Social Media (specify below)
Date of Incident
Date Picker Icon
Briefly describe the Incident. Provide as much information as possible to better aid investigation of the report.
Upload Pic / Video / Screenshot of Incident if available.
Would you be interested in participating in peer mediation? The peer mediator would be trained and a trained adult will also be present.
Yes (provide email above)
Any feedback on the actual form?
Should be Empty: