Anonymous Incident Report Form

School SchoolConway Grammar SchoolDeerfield Elementary SchoolFrontier Regional SchoolSunderland Elementary SchoolWhately Elementary School

I am a .... I am a ....Student reporting someting that happened to meStudent reporting something that I saw happen to another studentParent or family member reporting something that happened to my student

I am reporting a possible violation of... I am reporting a possible violation of...A student's right to non-discrimination regardless of race, color, physical or mental disability, homelessness, sex/gender, gender identity, religion, national origin, ancestry, or sexual orientation.A student's right to fair school disciplaine under the Code of Conduct.A student's right not tob e subject to sexual misconduct.

Where did the incident occur? Where did the incident occur?In a Text MessageIn a VoicemailIn an EMailIn an Instant MessageIn classIn front of schoolIn a hallwayIn a bathroomIn the cafeteriaIn the gymIn the locker roomIn the parking lotIn the Out of School Time programOff school groundsOn the busOn the fieldOn the playgroundSocial MediaOther

Type of Incident Type of IncidentConcern for Self or OthersDiscrimination or HarrassementSuspicion of physical abuse & misconductThreat to school or studentsCandalism (Nudity)Tip

When did the incident happen? Please provide day, date and time.

Who was bullying, harassing, intimidating or causing harm? Include first name, last name and grade if known.

Who was the person being harmed, bullied, harassed or intimidated? Include first name, last name and grade if known.

Were there any witnesses? Please list their first name, last name and grade if known.

Describe what happened. Give as much information as you can.

If you would like someone to contact you, please add your phone number.