INFORMATION ABOUT YOU
Your full name:
Your role in Lafayette School Corporation:
Your phone number:
Your email address:
Your local physical address:
Information about the Incident:
Urgency of this report:
Date of incident (mm/dd/yyyy):
Time of incident:
Location of incident:
Specific location:
PEOPLE INVOLVED
Please include information for anyone involved in this incident including witnesses. If more than three individuals are involved, submit an additional form.
Name of Person
Select Gender
Select Role
Date of Birth (mm/dd/yyyy)
Email Address
Phone Number
Name of Additional Person1
Select Gender
Select Role
Date of Birth (mm/dd/yyyy)
Email Address
Phone Number
Name of Additional Person2
Select Gender
Select Role
Date of Birth (mm/dd/yyyy)
Email Address
Phone Number
INCIDENT DETAILS
What happened? Please provide a detailed description of the alleged incident using specific concise, objective language (who, what, where, when, why, and how).
Has any law enforcement agency been notified?
If you answered “yes” to the previous question, please indicate which agency.
Has this been reported to any other Lafayette School Corporation teacher, administrator, or staff?
If you answered “yes” to the previous question, please identify the staff member(s).