Incident Report Form

Lewis Middle School Confidential Incident Report Form

I am a: *

During this incident I was a: *

What is your name? (OPTIONAL)

Were there more witnesses to this incident? If so, please include their name(s).

Where did the incident happen? Please be as specific as possible.

Did the incident happen only once or is it ongoing? *

Please rate the severity of the Incident(s), (1) being a minor incident but unacceptable to (5) being a major incident that could result in retaliation or violence. *

In this incident, were you able to try any strategies to solve the problem? If you are answeringYES, what are some things you said or did to solve the problem.

Did this or other incidents make you feel like harming yourself or others? *

How do you feel about this incident or person? (Examples: they are annoying, I hate them, I want to hurt them, they don't make me mad, I just want it to stop...etc.) *

Please describe the incident in detail. Please be as specific as possible. *



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