CYSO Incident Report Form

CYSO Incident Report Form
CYSO does not tolerate bullying, harassment, or threatening behavior, and we take reports of such behavior seriously. All reports will be investigated by CYSO staff to ensure that CYSO continues to be a safe learning environment.
Name of Reporter

We encourage you to include your name in this report. If you choose to include your name, CYSO will be better able to assist you/your child in resolving the situation and will be able to connect with you about the next steps. However, if you choose to make an anonymous report, a CYSO staff member will review the information and do their best to investigate (if appropriate) the situation.
Name of Reporter (leave blank if you wish to remain anonymous)

First NameLast Name
Are you a...*

StudentParentTeacherWitnessOther
Preferred Method of Contact

If you choose to submit a non-anonymous report and CYSO finds it necessary to follow up with you, how would you like to be contacted?

Note: If you would like your report to be anonymous, please leave this section blank.
Primary Contact Name

First NameLast Name
Primary Contact Phone Number

Area CodePhone Number
Primary Contact is a...

StudentParentCYSO TeacherSchool Teacher/AdministratorHealthcare Professional (doctor, counselor, therapist, etc.)Other
Primary Contact Email
example@example.com
Primary Contact Preferred Language
Who is Involved?

We encourage you to include the name(s) of those involved, which will allow CYSO staff to investigate the situation and work for a resolution. However, if you choose not to include the names of those involved, leave the question blank, and a CYSO staff member will review the information and do their best to investigate (if appropriate) the situation described.
Name(s) of those involved
Use a comma to separate multiple names, leave question blank if you do not wish to include names
Ensemble (please tell us your ensemble and/or the ensemble of the student(s) involved)*

Overture StringsPreparatory StringsAccelerando StringsDebut OrchestraConcert OrchestraPhilharmonic OrchestraSymphony OrchestraJumbies Steel EnsembleGroove Steel EnsembleJunior Steel OrchestraKaiso Steel OrchestraJazz OrchestraCYSO @ Moos ElementaryCYSO @ Nixon ElementaryOther
Incident Report
What kind of behavior are you reporting?*

Harassment/Intimidation (aggressively making someone feel less than)Exclusion (purposefully making someone feel not a part of the group)Physical Aggression (hitting, kicking, punching, shoving, etc.)Sexual Harassment (sexual comments, unwanted physical contact)Cyber-Disrespect (using social media or the internet to make someone feel uncomfortable)Threatening (actions and words that purposefully make someone feel afraid)Stealing or Damaging Property (taking or damaging someone else's possessions)Other
Is this a recurring event? (Has it happened before/have there been multiple incidents?)*

YesNo
Description (Please provide a description of the incident and when it happened.)*
Please describe the impact this incident has had.*
Should be Empty: