SBK8 Incident Student Reporting Form

If you are having an issue that you would like to an administrator or counselor to support you with, please fill out this form. An administrator or counselor will then email you at your school e-mail or call you out of class as a response to your form.

Your Name Your Name First Last
Your Grade Level

Your Grade Level 4th 5th 6th 7th
Your Student ID Number:
Student email (please add your student number before the @ symbol)
What type of incident is this?

What type of incident is this? Conflict with another student Something you observed Something that may be illegal or dangerous Other Other
Date of incident: Date of incident: / MM / DD YYYY
Time of Incident or class period of incident:
Where did the incident occur?

Where did the incident occur? Classroom Hallway Cafeteria Bus Bathroom Online
Give details about the incident that you need help with or want to report.
Names of witnesses or others involved that we might need to meet with.
Do you have items you want to share with us? Screenshots, photos, etc? Upload them here.

Attach Files
Sign the form to state that all information above is true to the best of your knowledge. Reporting false information could lead to school discipline.

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.