The School District of Escambia County
School Violence Reporting System
Report Teen Dating Violence
Is this report being given directly to a School District Employee?
If yes, Name of Person Receiving Report: 

* Indicates required field
 




*Select School:  
Your Name (Optional):  
First Name:
Last Name:
Who are you:         
Your Contact Information (Optional):  
Address:
City:
State:
Zip Code:
Primary Phone Number:
Alternate Phone Number:
*Victim(s):  
*Perpetrator:  
  *Describe the incident:  (who, what, when, where)
     
  *List all witness(es):
   
  Where did this incident take place? (select all that apply)
 
Other Location:
 
*How often has the bullying behavior occured?
select
 
Have you reported the bullying incident to anyone?       
If yes, to whom did you report the incident?
         
Version: 1.5