Person Reporting Incident
You may choose to report this information anonymously. All complaints will be treated in a confidential manner. Anonymous reports may limit the district’s ability to respond to the complaint.
Phone Number
Person completing this form

Name of Target
Name(s) of alleged offender(s)
Date(s) of Incident(s)
What is your School? *
Where did the incident happen?

If you select Other, please fill the "Other Place" field bellow.
Other Place
Place a check next to the statement(s) that best describes what happened (choose all that apply)

If you select Other, please fill the field "Other" bellow.
Background: Please describe what happened before, during and after the incident
Who else saw the incident occur?
What steps, if any, have been tried to resolve the issue?
To your knowledge, was the student victim absent from school as a result of the incident?