EmailMe Form - Reading Public Schools

Name of Reporting/Person filing the report: (not required)
First Last
Your Phone Number
### - ### - ####
Your Email
Select whether you are the:
Target of the behavior
Reporter (not the target)
Select whether you are:
Student
Staff Member
Parent
Administrator
Other
If Student, please select your school:
Grade of Submitter:
If staff member, state your school or work site:
Information regarding the incident:
Name of target of behavior:
First Last
School of Target:
Grade of Target
Name of Agressor (Person who engaged in the behavior):
First Last
School of Agressor:
Grade of Agressor
Date and Time of Incident
MM / DD / YYYY HH : MM AM/PM
Location of Incident(s) (Please be as specific as Possible):
Is there an online/Internet component of this incident? Please Describe:
Witnesses
Please list people who saw the incident or have information about it.
Describe the details of the incident, including names of people involved, what occurred, and what each person did and said.