Today's Date: Date of Incident:
What was the nature of the incident? (drug or alcohol, bullying, fighting, harassment, abuse, illegal, other) Drug/AlcoholBullyingFightingHarassmentAbuseIllegalOther, please specify
I was: VictimWitnessBystanderOther, please specify
Where did the incident take place?
Who were the people involved? (Please state the role of each person: witness (W), victim (V), participant (P) or other (O).
RoleWitnessVictimParticipantOther
Write a description of the incident. (Be specific)
Is an adult aware of this situation? YesNo
If yes, who?
If you want to be contacted please enter your name and how to contact you (Optional).