Central Wisconsin Christian School

Where Christ is Central
General HS 1

Incident Report Form

Before filling out this form, have you worked through our conflict resolution steps? If not, please see the Conflict Resolution page.

1.
* Person Reporting the Incident: Name
2.
* Telephone Number:
3.
* Email Address:
4.
* Are you a:
Student   Parent/Guardian
Friend   Staff
5.
* Date of Incident:
6.
* Time of Incident:
7.
Frequency of Incident:
8.
* Where did the incident happen? (Check all that apply) (1 required)
on school property   on a school bus
electronically (ie internet, email, cellphone)   at school sponsored event
on the way home from school
9.
* Which statement best describes what happened? (1 required)
Social Exclusion   Sexual Harrasment
Theft   Violation of Rules of School Conduct
Threats   Public Humiliation
Destruction of Property   Gossip/Slander
Physical Violence

Persons Involved (In the event of bullying or harassment, please give both names, for other incidents, give the name of those accused):

10.
* Name of person targeted:
11.
* Name(s) of person accused:
12.
* Briefly describe what happened:

* Email Address: