Today's Date: (MM/DD/YYYY)

Date of Incident:(MM/DD/YYYY)

What was the nature of the incident? (drug or alcohol, bullying, fighting, harassment, abuse, illegal, other)

Drug/Alcohol

Bullying

Fighting

Harassment

Abuse

Illegal matter

Other, please specify

       

 

I was

A victim

A Witness

A Bystander

Other, please specify


Where did the incident take place?

Who were the people involved?  (Please state whether they were a witness (W), victim (V), Participant (P) or Other (O).
  Name School Role-W,V,P,O
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6

Write a description of the incident.  (Be specific)



Is an adult aware of this situation? Yes No

If yes, who?

If you want to be contacted please enter your name and how to contact you. (Optional)