SMUSD Incident Reporting Form
Complete this form if you have credible information regarding a mistreatment incident and want to report it anonymously. This form is completely anonymous; formal disciplinary action may not be based solely on the basis of this report or an anonymous phone call. Please type or print clearly.

This report will be investigated in a timely manner. If you fear a student is in IMMEDIATE danger, contact the appropriate resource (i.e., the principal of the school, assistant principal) or CALL the Police at 911.
Sign in to Google to save your progress. Learn more
Victim's Name / Person Harmed (Alleged) *
(Last, First)
Victim's School Site
Clear selection
Age
(Alleged Victim)
Grade
(Alleged Victim)
Gender
(Alleged Victim)
Perpetrator's Name / Person Who Hurt Someone (Alleged) *
(Last, First)
Alleged Perpetrator's School
Clear selection
Age
(Alleged Perpetrator's)
Grade
(Alleged Perpetrator's)
Gender
(Alleged Perpetrator's)
Where did the incident occur? *
Be specific (i.e., classroom, hallway, cafeteria, playground, bus).
Required
When did the incident occur? *
Time can be approximate.
MM
/
DD
/
YYYY
Time
:
What happened? *
Describe in detail.
Were there any witnesses? *
Names of witnesses.
Provide their name(s) and contact information.
List any evidence of mistreatment.
(i.e., letters, texts, photos, etc)
Was there a previous report filed by anyone regarding this incident? *
When was the previous report filed?
MM
/
DD
/
YYYY
Was there a police report filed? *
When was the police report filed?
MM
/
DD
/
YYYY
Have you been mistreated or witnessed mistreatment by this person before? *
If so, how many times?
Was a report filed for the previous time(s)?
When was the report filed?
MM
/
DD
/
YYYY
Email Address (to receive a copy of this submission & for follow up)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of San Marino Unified School District. Report Abuse
Google Forms