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SAFETY & SECURITY INCIDENT FORM

Use the following form to report a bullying, safety, security, or threat incident.

Today's Date:
Date & Time of Incident:
Who was engaged in the incident?
Grade level of student engaged in the incident:
Who was being bullied or threatened?
Grade level of student:
What type of incident took place?



Where did the incident take place?
Describe what happened with as many details as possible.
Full name of person reporting the incident. (Optional)
May we contact you for more information concerning this incident?
Email Address:
Phone Number: