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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.
Name (Optional)
First Name
Last Name
Email (Optional, but useful for follow-up and if you want a copy of your responses)
example@example.com
Incident Type
Please Select
Bullying
Cyberbullying
Sexual Misconduct
Cheating
Discrimination (specify below)
Threat (Physical)
Threat (Verbal)
Other
Incident Location
Please Select
Classroom
Hallway
Cafeteria
School Grounds
Field trip(specify below)
eMail
Social Media (specify below)
Other
Date of Incident
-
Month
-
Day
Year
Date Picker Icon
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Briefly describe the Incident. Provide as much information as possible to better aid investigation of the report.
Eyewitnesses, Bystanders
Upload Pic / Video / Screenshot of Incident if available.
Upload a File
Cancel
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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)
Maybe
No
Any feedback on the actual form?
Submit
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