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KOMAREK ANONYMOUS INCIDENT REPORT FORM

Please complete the form below. Required fields marked *

Instructions: To anonymously report an incident, please complete the fields below. Please note that information submitted is confidential and will be sent to the district Social Worker and Administrators.

Date of Incident:*

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Time of Incident:

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Students Involved:

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Grade(s):

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Incident Description (Please be as descriptive as possible)*

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Parent and student identities will be kept completely confidential and responses will not be linked to any individual. We guarentee that survey responses will never be connected to you or your child.

Optional Information

Your name:

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Your Phone Number:

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Your E-mail Address:

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