TIPS

Student Safety/Well-Being Reporting Form

Name of Person Filing the Report:

Select a date

(Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.)

Select whether you are the:

Select whether you are a:

Information about the incident:

Name of Target (of behavior:)

Name of Agressor (Person who engaged in the bahavior):

Date(s) of Incident(s):

Time When Incident(s) Occurred:

Location of Incident(s) (Be Specific as Possible):

Witnesses (List people who saw the incident or have information

Name:

Student Staff Parent Patron

Name:

Student Staff Parent Patron

Name:

Student Staff Parent Patron

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used.)