Incident Report Form CCCL

This form is for students, parents, and others within our school community to report an incident of concern to school leaders.

Date of Incident

Must contain a date in MM/DD/YYYY format

Time of Incident

Describe what happened. Please be as specific as possible. Include dates, times, description of what was stolen or found, behaviors that led up to the incident, etc.

Where did it happen?

Have you reported the incident yet? If so, to whom? (teacher, parent, etc.)

Were there any witnesses? If so, please list their names.

Your Namerequired

First Name

Last Name

If possible, would you like us to keep your name confidential?

Yes

No

Which school do you attend or work in?Please select up to 1 choice

City High School

Paulo Freire Freedom School-Downtown

Paulo Freire Freedom School-University

Please select up to 1 choice

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Incident Report Form