Incident Report

Use this form to submit a concern you have and someone will follow up with you in person or through your school email.

Your Year Level

Your Year Level Year One Year Two Year Three
Follow Up (Staff Only)
Your First Name
Your Last Name
Your Student Number (Lunch Number)
Put your student number at the start of the address so you can get a copy of this.
Upload a photo of JUST YOU so we can confirm who is submitting this form

Attach Files
What kind of incident statement is this?

What kind of incident statement is this? Telling us about an issue you have getting along with someone (social/personal) Telling us about an incident you were a part of Telling us about something you observed Telling us about something that may be illegal
Date of Incident Date of Incident / MM / DD YYYY
Time of Incident (to the best of your knowledge)
Where Incident Happened
Describe What Happened - What YOU saw and heard, not what others have told you.
Is this an IMMEDIATE FUTURE PHYSICAL THREAT to someone or the school?

Is this an IMMEDIATE FUTURE PHYSICAL THREAT to someone or the school? YES No
What have you heard from OTHER people about this?
People Involved (First and Last Names. Describe them if you don't know their name.) - Do your best to spell names, we will figure it out.
Witnesses - People who saw it but weren't involved - (First and Last Names. Describe them if you don't know their name.) - Do your best to spell names, we will figure it out.
Do you have something to share? Upload a photo or video here.

Attach Files
Have you seen information about this on social media?

Have you seen information about this on social media? No Snapchat Instagram Text Message Other Other
Who posted it and when?
Sign this incident report. Signing says that everything you've stated is true. If there is anything NOT true, go back and change it. If you submit false information, you may receive a discipline referral.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.