Anonymous Incident Report

	Anonymous Incident Report **CONFIDENTIAL**

	Name (Optional)
	First   Last

	Contact Information (Optional)
	Phone   E-mail

	Describe the incident or situation you wish to report.

	Location of incident:* Select at least 0 and no more than 0.
	Currituck County High School  J.P. Knapp Early College  Currituck County Middle School  Moyock Middle School  Moyock Elementary School   Shawboro Elementary School  Knotts Island Elementary School  Central Elementary School  W.T. Griggs Elementary School  Jarvisburg Elementary School   Other, please specify

	When AND Where did the incident occur?

	Would you like to speak with your counselor/administrator concerning this situation?

	Has this incident been reported before?
	Has this incident been reported before? YesNo