Indicate if there are witnesses who can provide more information regarding your report. If the
witnesses are not school district staff or students, please provide contact information.
Name
Address
Telephone Number
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________________
Have there been previous incidents (circle one)?
Yes
No
If “yes”, please describe the behavior of concern, or the violence that occurred; the approximate
dates and the location:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
________________________________________________________________________________________
Were these incidents reported to school employees (circle one)
Yes
No
If “Yes”, to whom was it reported and when?
_____________________________________________________________________________________________
Was the report verbal or written?
_____________________________________________________________________________________________
Proposed Solution:
Indicate your opinion on how this problem might be resolved in the school setting. Be as specific
as possible.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I certify that the above information and events are accurately depicted to the best of my
knowledge.
_____________________________________________
Signature of Reporter
Date
Submitted
__________________________________________
Received
By
Date Received
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