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MUNICIPAL SCHOOL DISTRICT MUNICIPAL SCHOOL DISTRICT

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School Safety Form

School Safety Form

Please complete this form to the best of your knowledge so we can assist you.
This information will be kept confidential with your campus administrator and/or superintendent.

School Safety Report

Date of Incident:

Date of Report:

Who was the person(s) engaged in bullying or threatening school safety?
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Grade of person(s) being reported?
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Who was being bullied or threatened?
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Grade of person who was being bullied?
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What type of threat is being reported?

Physical

Emotional/Social

Damage to Property

Online

Bullying

If Safety Threat- what is being threatened?

After School Program

Bus

Bus Stop

Cell Phone

Classroom

Hallway

Gym

Internet

Locker Room

Lunch Room

Parking Lot

Playground

Restroom

School Sponsored Event

Other

Other

If Bullying - where did the incident take place?

After School Program

Bus

Bus Stop

Cell Phone

Classroom

Hallway

Gym

Internet

Locker Room

Lunch Room

Parking Lot

Playground

Restroom

School Sponsored Event

Other

Other

Other Helpful Information:
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Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe issue with as many details as possible.

Person reporting the incident:(OPTIONAL). Please use your full name.
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May we contact you for more information on this incident?

Yes

Phone Number
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Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.

Email a copy to

optional

Required Fields

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