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Safe and Supportive Incident Reporting Form

Victoria ISD has a strong policy regarding student welfare and crisis intervention. If a student is exposed to harmful, threatening, or violent behavior at school, immediately report the incident to the principal or assistant principal, who will investigate the situation.

A parent or student can make this report by completing the form below or by talking to school officials. If counseling resources are needed because a child is a victim or witness to a threat, please contact your school's counselor.

Today's date:*

Answer Required

Name of person completing this form (optional):

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Relationship to alleged victim/offender (optional):

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Contact number (optional):

Number Required

Incident Information:

Name of student who displayed harmful, threatening, or violent behavior:*

Answer Required

Intended target/victim name #1:*

Answer Required

Intended target/victim grade level #1*

Answer Required

Intended target/victim name #2:

Answer Required

Intended target/victim grade level #2:

Answer Required

Intended target/victim name #3:

Answer Required

Intended target/victim grade level #3:

Answer Required

Incident Information

Date of the incident:*

Answer Required

Time of the incident:*

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Where did the incident occur?*

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Incident description:*

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Name(s) of witness(es) to incident:

Witness name #1*

Answer Required

Witness name #2

Answer Required

Witness name #3

Answer Required

Witness name #4

Answer Required

Has an adult at school helped you with this incident?*

Answer Required

Yes

If yes, who was it and what was done?

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Is this the first incident?*

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Yes

If no, how many times has this happened before?

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Please provide information about previous incidents including the name(s) of school staff to whom these previous reports were made.

Answer Required

Agreement

I certify that all statements made on this form are true, correct, and complete. Any intentional misstatement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary to pursue the investigation.

Type your full name here for a digital signature (optional)

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Confirmation Email

Enter your email address here if you'd like to receive a confirmation upon submitting the form.

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