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Confidential Safety Report Form

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).

Write a description of the incident. (Be specific)

Is an adult aware of this situation?

If yes, who?

If you want to be contacted please enter your name and how to contact you (Optional).