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Incident Report

indicates a required answer

1. *

Your First and Last Name:
2. *

Your Email Address:
3. *

Your Phone Number:
4. *

Contact Preference:

 (1 required)
Email Text
Phone Call
5. *

Date and Time of Incident:
6. *

Location (Classroom, playground, lunch area, teen event, field trip, etc.):
7. *

Nature of the Concern

 (1 required)
Classroom concern Teacher/student interaction
Verbal aggression Bullying/harassment
Safety concern Property damage
Medical/injury Board policy concern
Facilities/property concern Financial/payment concern
Administrative/process concern Other
8. *

Description of Concern

  • Briefly describe what happened

  • Who was involved?

  • When and where did it occur?

  • Was this a one-time situation or ongoing?

  • Has this been discussed with anyone already?
    (Teacher, parent, board member, etc.)
9. *

Response & Action Taken

  • Immediate steps taken by adult and/or children involved - 

    • EXAMPLES - Verbal redirection, Removal from class/activity, First aid, Conflict resolution, Parent contacted, Other — specifc
10. *

Desired Outcome

  • I want someone to be aware

  • I am requesting board follow-up

  • I need mediation or support resolving it

  • I want a policy change

  • Other — describe
11. 

Documentation (optional)

  • Photos (injury or property damage if applicable)

  • Written statements from witnesses

  • Emails/texts related to the situation

Allowed extensions: csv, doc, docx, dot, gif, heic, heif, htm, html, jpeg, jpg, m4a, mov, mp3, mp4, pdf, png, pps, ppt, pptx, pub, rtf, svg, txt, xls, xlsx, yyz, zip
12. 

Any additional information?
13. *

 I verify that all information shared is accurate to the best of my ability.
 
14. *

I understand that Eastside Explorers leadership may need to contact others involved to resolve this issue.
15. *

By typing your name below, you acknowledge that:

  • The information provided in this form is true and accurate to the best of your knowledge.

  • You understand that Eastside Explorers board leadership may reach out for clarification or follow-up.

  • You agree to communicate in good faith and participate respectfully in resolving this concern.

 
By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.
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