Anonymous Reporting

1.	Name: This is not a required, but would be appreciated. This report will be kept confidential and your identity will remain anonymous.

2.	In order to address this incident quickly, please choose the school that this incident impacts. If this incident impacts more than one school, please choose only one and then write additional names in the comments section: Select at least 1 and no more than 1.
	Fieler  Iddings  Miller  Salk  Wood   Merrillville Intermediate  Clifford Pierce Middle School  Merrillville High School   Other, please specify

3.	When did this incident occur? (if this incident has not yet occurred, but there have been threats made, please indicate when the threats were made):
	mm/dd/yyyy

4.	Where did this incident happen? If there was more than one incident, please select the location of the most recent incident. If there are multiple locations or you would like to elaborate on the location, please write in the box below.
	In the classroom    In the hallway    On the Bus    In the cafeteria    Outside of school    On the internet    Other, please specify

5.	Name of the target of this incident (if there is more than 1 target, please write one name in this box and then write the other names in the comments section):

6.	Comments

7.	Grade (if there is more than one grade, pick the grade for the target named above):
	--None--K123456789101112

8.	Name of the perpetrator(s) of this incident (if you do not know the name of the perpetrator, please write unknown.):

9.	Were there any witnesses? (if yes, please list names or a description of who they are, ex. young boy with a blue hoodie, adult that looked like a security guard):