ERROR:
JavaScript is not enabled. You must enable JavaScript in your browser to use this form
Please fill in a valid value for all required fields
Please ensure all values are in a proper format.
Are you sure you want to leave this form and resume later?
Are you sure you want to leave this form and resume later? If so, please enter a password below to securely save your form.
Save and Resume Later
Save and get link
You must upload one of the following file types for the selected field:
There was an error displaying the form. Please copy and paste the embed code again.
Apply Discount
You saved
with code
Submit Form
Submitting
Validating
There was an error initializing the payment processor on this form. Please contact the form owner to correct this issue.
Please check the field:
Fields
Report Safety Concern
Would you prefer to remain anonymous?
*
Yes
No
If you would like to contacted regarding the incident(s), you will need to provide your information.
Name
First Name
Last Name
Would you like to be contacted regarding this incident(s)?
*
Yes
No
How would you like to be contacted?
Phone
In Person
Email
Phone
Email
Event Description: (Including... Who, What, When, Where and How Do You Know)
Concern/Event Type (Select the option that fits best)
*
Please select from list below:
Alcohol Possession/Distribution/Use
Anger Issues/Creating Hostile Environment
Assault/Intend to Harm Others
Bodily Injury/Emergency Condition
Building/Physical Safety & Security (doors, etc.)
Bullying/Cyber-bullying/Teasing
Bus Safety/Transportation Concerns
Child Abuse/Neglect
Computer/Technology Misuse/Cyber Concerns
Dating Violence/Domestic Violence
Depression/Anxiety
Discrimination
Distribution of Inappropriate Photos
Drug Distribution/Use/Sale/Abuse
Eating Disorder
Fighting
Gang Violence/Formation/Threats
General School Complaint/School Accountability
Guns
Harassment/Hazing
Hate Crime/Hate Speech
Inappropriate Behavior/Language/Gestures
Knife
Location of Missing Child/Student
Planned Fights
Planned School Attack
Sexual Assault/Rape
Sexual Harassment/Misconduct/Sexting
Skipping School/Truancy/Ditching
Smoking/E-cigs/Vaping
Suicide Threats/Thoughts of Suicide
Theft/Stealing
Trespassing
Unresponsive/Unconscious Individual
Vandalism/Destruction of Property
Other
If selected 'other,' please explain
Describe what happened
*
What time and date did the event occur to the best of your recollection?
*
Any Other Comments
File Upload
File
No File Chosen
File uploads may not work on some mobile devices.
File Description
Does your upload contain inappropriate content such as sexually explicit content?
Yes
No
Previous
←
Next
→
Powered by Formstack
Create your own form
›
Enter your save and resume password
Cancel
Confirm