Section I. GENERAL INFORMATION Today's Date: - must be mm/dd/yyyy format * Required
School: Unknown/Other Academy at Palumbo AMY Northwest Adaire, Alexander Allen, Ethan Allen, Ethel Alternative Middle Years at James Martin Anderson, Add B. Arthur, Chester A. Arts Academy at Benjamin Rush Bache-Martin School Baldi School Barry, John Barton, Clara Bartram, John Bethune, Mary M. Blaine, James G. Blankenburg, Rudolph Bodine, William W. Bregy, F. Amedee Bridesburg School Brown, Henry A. Brown, Joseph H. Bryant, William Building 21 Carnell, Laura H. Carver HS of Engineering and Science Cassidy, Lewis C. Catherine, Joseph W. Cayuga School Central High School Childs, George W. Clemente, Roberto Comegys, Benjamin B. Comly, Watson Constitution High School Conwell, Russell Cook-Wissahickon School Cooke, Jay Cramp, William Creative and Performing Arts Crossan, Kennedy C. Crossroads Accelerated Academy Crossroads @ Hunting Park Day, Anna B. de Burgos, Julia Decatur, Stephen Dick, William Disston, Hamilton Dobbins, Murrell Dobson, James Duckrey, Tanner Dunbar, Paul L. Edison, Thomas A. Edmonds, Frankin Elkin, Lewis Ellwood School Emlen, Eleanor Farrell, Louis H. Fell, D. Newlin Fels, Samuel Feltonville Intermediate School Feltonville School of Arts and Sciences Finletter, Thomas K. Fitler, Edwin H. Fitzpatrick, Aloysius L. Forrest, Edwin Fox Chase School Frank, Anne Frankford High School Franklin Learning Center Franklin, Benjamin Franklin, Benjamin (elementary) Furness, Horace Gideon, Edward Girard Academic Music Program Girard, Stephen Gompers, Samuel Greenberg, Joseph Greenfield, Albert M. Hackett, Horatio B. Hamilton, Andrew Hancock, John Harding, Warren G. Harrington, Avery D. Hartranft, John F. Henry, Charles W. Heston, Edward High School of the Future Hill-Freedman World Academy Holme, Thomas Hopkinson, Francis Houston, Henry Howe, Julia W. Huey, Samuel B. Hunter, William H. Jackson, Andrew Jenks, A.S. Jenks, John S. Juniata Park Academy Kearny, General Phillip Kelley, William D. Kelly, John B. Kenderton School Kensington Health Sciences Academy Kensington HS for Creative & Performing Arts Kensington High School Key, Francis Scott King, Martin Luther Kirkbride, Elizabeth LaBrum, General J. Henry Lamberton, Robert Lankenau High School Lawton, Henry W. Lea, Henry C. Leeds, Morris Lincoln, Abraham Lingelbach, Anna L. Locke, Alain Loesche, William H. Logan, James Longstreth, William Lowell, James R. Ludlow, James R. Marshall, John Marshall, Thurgood Mastbaum, Jules E. Masterman, Julia R. Mayfair School McCall, General George McCloskey, John F. McClure, Alexander McDaniel, Delphaine McKinley, William McMichael, Morton Meade, General George G. Meehan, Austin Meredith, William M. Middle Years Alternative School Mifflin, Thomas Mitchell, S. Weir Moffet, John Moore, J. Hampton Morris, Robert Morrison, Andrew J. Morton, Thomas G. Motivation High School Munoz-Marin, Luis Nebinger, George W. Northeast High School Olney School Overbrook Educational Center Overbrook Elementary Overbrook High School Parkway Center City High School Parkway Northwest High School Parkway West High School Patterson, John M. Peirce, Thomas M. Penn Alexander School Penn Treaty High School Pennell, Joseph Pennypacker, Samuel Penrose School Phila. Learning Academy North Phila. Learning Academy South Philadelphia High School for Girls Philadelphia Military Academy Philadelphia Virtual Academy Pollock, Robert B. Potter-Thomas School Powel, Samuel Prince Hall School Randolph, A. Phillip Rhawnhurst School Rhoads, James Rhodes, E. Washington Richmond School Robeson, Paul Roosevelt, Theodore Rowen, William Roxborough High School Saul, Walter B. Sayre, William L. Science Leadership Academy Science Leadership Academy MIddle School Science Leadership Academy at Beeber Sharswood, George W. Shawmont School Sheppard, Isaac Sheridan, Phillip Solis-Cohen, Solomon South Philadelphia High School Southwark School Spring Garden School Spruance, Gilbert Stanton, Edwin M. Stearne, Allen M. Steel, Edward Strawberry Mansion High School Sullivan, James J. Swenson Arts and Technology HS Taggart, John H. Taylor, Bayard The LINC The U School The Workshop School Tilden, William Vare-Washington School Vaux Wagner, General Louis Waring, Laura W. Washington Jr., Grover Washington, George Washington, Martha Webster, John Welsh, John West Philadelphia High School Widener Memorial School Willard, Frances Wilson, Woodrow Wright, Richard R. Ziegler, William H.
Your Name: * Required
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(Name of person filling out the form)
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Email:
I am: * Required Is someone helping you fill out this form? * Required If so, who?
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If so, what is that person's role? If so, what is that person's email address?
Interpreter services needed? * Required Alleged Victim Information (Complete separate form for each victim)
Alleged Victim's Name: * Required
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Last
Alleged Victim's School: * Required Unknown/Other Academy at Palumbo AMY Northwest Adaire, Alexander Allen, Ethan Allen, Ethel Alternative Middle Years at James Martin Anderson, Add B. Arthur, Chester A. Arts Academy at Benjamin Rush Bache-Martin School Baldi School Barry, John Barton, Clara Bartram, John Bethune, Mary M. Blaine, James G. Blankenburg, Rudolph Bodine, William W. Bregy, F. Amedee Bridesburg School Brown, Henry A. Brown, Joseph H. Bryant, William Building 21 Carnell, Laura H. Carver HS of Engineering and Science Cassidy, Lewis C. Catherine, Joseph W. Cayuga School Central High School Childs, George W. Clemente, Roberto Comegys, Benjamin B. Comly, Watson Constitution High School Conwell, Russell Cook-Wissahickon School Cooke, Jay Cramp, William Creative and Performing Arts Crossan, Kennedy C. Crossroads Accelerated Academy Crossroads @ Hunting Park Day, Anna B. de Burgos, Julia Decatur, Stephen Dick, William Disston, Hamilton Dobbins, Murrell Dobson, James Duckrey, Tanner Dunbar, Paul L. Edison, Thomas A. Edmonds, Frankin Elkin, Lewis Ellwood School Emlen, Eleanor Farrell, Louis H. Fell, D. Newlin Fels, Samuel Feltonville Intermediate School Feltonville School of Arts and Sciences Finletter, Thomas K. Fitler, Edwin H. Fitzpatrick, Aloysius L. Forrest, Edwin Fox Chase School Frank, Anne Frankford High School Franklin Learning Center Franklin, Benjamin Franklin, Benjamin (elementary) Furness, Horace Gideon, Edward Girard Academic Music Program Girard, Stephen Gompers, Samuel Greenberg, Joseph Greenfield, Albert M. Hackett, Horatio B. Hamilton, Andrew Hancock, John Harding, Warren G. Harrington, Avery D. Hartranft, John F. Henry, Charles W. Heston, Edward High School of the Future Hill-Freedman World Academy Holme, Thomas Hopkinson, Francis Houston, Henry Howe, Julia W. Huey, Samuel B. Hunter, William H. Jackson, Andrew Jenks, A.S. Jenks, John S. Juniata Park Academy Kearny, General Phillip Kelley, William D. Kelly, John B. Kenderton School Kensington Health Sciences Academy Kensington HS for Creative & Performing Arts Kensington High School Key, Francis Scott King, Martin Luther Kirkbride, Elizabeth LaBrum, General J. Henry Lamberton, Robert Lankenau High School Lawton, Henry W. Lea, Henry C. Leeds, Morris Lincoln, Abraham Lingelbach, Anna L. Locke, Alain Loesche, William H. Logan, James Longstreth, William Lowell, James R. Ludlow, James R. Marshall, John Marshall, Thurgood Mastbaum, Jules E. Masterman, Julia R. Mayfair School McCall, General George McCloskey, John F. McClure, Alexander McDaniel, Delphaine McKinley, William McMichael, Morton Meade, General George G. Meehan, Austin Meredith, William M. Middle Years Alternative School Mifflin, Thomas Mitchell, S. Weir Moffet, John Moore, J. Hampton Morris, Robert Morrison, Andrew J. Morton, Thomas G. Motivation High School Munoz-Marin, Luis Nebinger, George W. Northeast High School Olney School Overbrook Educational Center Overbrook Elementary Overbrook High School Parkway Center City High School Parkway Northwest High School Parkway West High School Patterson, John M. Peirce, Thomas M. Penn Alexander School Penn Treaty High School Pennell, Joseph Pennypacker, Samuel Penrose School Phila. Learning Academy North Phila. Learning Academy South Philadelphia High School for Girls Philadelphia Military Academy Philadelphia Virtual Academy Pollock, Robert B. Potter-Thomas School Powel, Samuel Prince Hall School Randolph, A. Phillip Rhawnhurst School Rhoads, James Rhodes, E. Washington Richmond School Robeson, Paul Roosevelt, Theodore Rowen, William Roxborough High School Saul, Walter B. Sayre, William L. Science Leadership Academy Science Leadership Academy Middle School Science Leadership Academy at Beeber Sharswood, George W. Shawmont School Sheppard, Isaac Sheridan, Phillip Solis-Cohen, Solomon South Philadelphia High School Southwark School Spring Garden School Spruance, Gilbert Stanton, Edwin M. Stearne, Allen M. Steel, Edward Strawberry Mansion High School Sullivan, James J. Swenson Arts and Technology HS Taggart, John H. Taylor, Bayard The LINC The U School The Workshop School Tilden, William Vare-Washington School Vaux Wagner, General Louis Waring, Laura W. Washington Jr., Grover Washington, George Washington, Martha Webster, John Welsh, John West Philadelphia High School Widener Memorial School Willard, Frances Wilson, Woodrow Wright, Richard R. Ziegler, William H.
Alleged Victim's Grade: * Required K 1 2 3 4 5 6 7 8 9 10 11 12
Alleged Victim's Age: * Required
Alleged Victim's Race: * Required White/Caucasian Black/African-American Latino American Indian/Native Alaskan Asian/Pacific Islander Other
Alleged Victim's Sex: Does the alleged victim have a current IEP or Section 504 Plan? * Required Accused Person 1 Accused Person's School: * Required Unknown/Other Academy at Palumbo AMY Northwest Adaire, Alexander Allen, Ethan Allen, Ethel Alternative Middle Years at James Martin Anderson, Add B. Arthur, Chester A. Arts Academy at Benjamin Rush Bache-Martin School Baldi School Barry, John Barton, Clara Bartram, John Bethune, Mary M. Blaine, James G. Blankenburg, Rudolph Bodine, William W. Bregy, F. Amedee Bridesburg School Brown, Henry A. Brown, Joseph H. Bryant, William Building 21 Carnell, Laura H. Carver HS of Engineering and Science Cassidy, Lewis C. Catherine, Joseph W. Cayuga School Central High School Childs, George W. Clemente, Roberto Comegys, Benjamin B. Comly, Watson Constitution High School Conwell, Russell Cook-Wissahickon School Cooke, Jay Cramp, William Creative and Performing Arts Crossan, Kennedy C. Crossroads Accelerated Academy Crossroads @ Hunting Park Day, Anna B. de Burgos, Julia Decatur, Stephen Dick, William Disston, Hamilton Dobbins, Murrell Dobson, James Duckrey, Tanner Dunbar, Paul L. Edison, Thomas A. Edmonds, Frankin Elkin, Lewis Ellwood School Emlen, Eleanor Farrell, Louis H. Fell, D. Newlin Fels, Samuel Feltonville Intermediate School Feltonville School of Arts and Sciences Finletter, Thomas K. Fitler, Edwin H. Fitzpatrick, Aloysius L. Forrest, Edwin Fox Chase School Frank, Anne Frankford High School Franklin Learning Center Franklin, Benjamin Franklin, Benjamin (elementary) Furness, Horace Gideon, Edward Girard Academic Music Program Girard, Stephen Gompers, Samuel Greenberg, Joseph Greenfield, Albert M. Hackett, Horatio B. Hamilton, Andrew Hancock, John Harding, Warren G. Harrington, Avery D. Hartranft, John F. Henry, Charles W. Heston, Edward High School of the Future Hill-Freedman World Academy Holme, Thomas Hopkinson, Francis Houston, Henry Howe, Julia W. Huey, Samuel B. Hunter, William H. Jackson, Andrew Jenks, A.S. Jenks, John S. Juniata Park Academy Kearny, General Phillip Kelley, William D. Kelly, John B. Kenderton School Kensington Health Sciences Academy Kensington HS for Creative & Performing Arts Kensington High School Key, Francis Scott King, Martin Luther Kirkbride, Elizabeth LaBrum, General J. Henry Lamberton, Robert Lankenau High School Lawton, Henry W. Lea, Henry C. Leeds, Morris Lincoln, Abraham Lingelbach, Anna L. Locke, Alain Loesche, William H. Logan, James Longstreth, William Lowell, James R. Ludlow, James R. Marshall, John Marshall, Thurgood Mastbaum, Jules E. Masterman, Julia R. Mayfair School McCall, General George McCloskey, John F. McClure, Alexander McDaniel, Delphaine McKinley, William McMichael, Morton Meade, General George G. Meehan, Austin Meredith, William M. Middle Years Alternative School Mifflin, Thomas Mitchell, S. Weir Moffet, John Moore, J. Hampton Morris, Robert Morrison, Andrew J. Morton, Thomas G. Motivation High School Munoz-Marin, Luis Nebinger, George W. Northeast High School Olney School Overbrook Educational Center Overbrook Elementary Overbrook High School Parkway Center City High School Parkway Northwest High School Parkway West High School Patterson, John M. Peirce, Thomas M. Penn Alexander School Penn Treaty High School Pennell, Joseph Pennypacker, Samuel Penrose School Phila. Learning Academy North Phila. Learning Academy South Philadelphia High School for Girls Philadelphia Military Academy Philadelphia Virtual Academy Pollock, Robert B. Potter-Thomas School Powel, Samuel Prince Hall School Randolph, A. Phillip Rhawnhurst School Rhoads, James Rhodes, E. Washington Richmond School Robeson, Paul Roosevelt, Theodore Rowen, William Roxborough High School Saul, Walter B. Sayre, William L. Science Leadership Academy Science Leadership Academy Middle School Science Leadership Academy at Beeber Sharswood, George W. Shawmont School Sheppard, Isaac Sheridan, Phillip Solis-Cohen, Solomon South Philadelphia High School Southwark School Spring Garden School Spruance, Gilbert Stanton, Edwin M. Stearne, Allen M. Steel, Edward Strawberry Mansion High School Sullivan, James J. Swenson Arts and Technology HS Taggart, John H. Taylor, Bayard The LINC The U School The Workshop School Tilden, William Vare-Washington School Vaux Wagner, General Louis Waring, Laura W. Washington Jr., Grover Washington, George Washington, Martha Webster, John Welsh, John West Philadelphia High School Widener Memorial School Willard, Frances Wilson, Woodrow Wright, Richard R. Ziegler, William H.
Accused Person's Name:
First
Last
Accused Person's Grade: Unknown K 1 2 3 4 5 6 7 8 9 10 11 12
Accused Person's Age:
Accused Person's Race: Unknown White/Caucasian Black/African-American Latino American Indian/Native Alaskan Asian/Pacific Islander Other
Accused Person's Sex: Accused Person 2 (if applicable) Accused Person's School: Unknown/Other Academy at Palumbo AMY Northwest Adaire, Alexander Allen, Ethan Allen, Ethel Alternative Middle Years at James Martin Anderson, Add B. Arthur, Chester A. Arts Academy at Benjamin Rush Bache-Martin School Baldi School Barry, John Barton, Clara Bartram, John Bethune, Mary M. Blaine, James G. Blankenburg, Rudolph Bodine, William W. Bregy, F. Amedee Bridesburg School Brown, Henry A. Brown, Joseph H. Bryant, William Building 21 Carnell, Laura H. Carver HS of Engineering and Science Cassidy, Lewis C. Catherine, Joseph W. Cayuga School Central High School Childs, George W. Clemente, Roberto Comegys, Benjamin B. Comly, Watson Constitution High School Conwell, Russell Cook-Wissahickon School Cooke, Jay Cramp, William Creative and Performing Arts Crossan, Kennedy C. Crossroads Accelerated Academy Crossroads @ Hunting Park Day, Anna B. de Burgos, Julia Decatur, Stephen Dick, William Disston, Hamilton Dobbins, Murrell Dobson, James Duckrey, Tanner Dunbar, Paul L. Edison, Thomas A. Edmonds, Frankin Elkin, Lewis Ellwood School Emlen, Eleanor Farrell, Louis H. Fell, D. Newlin Fels, Samuel Feltonville Intermediate School Feltonville School of Arts and Sciences Finletter, Thomas K. Fitler, Edwin H. Fitzpatrick, Aloysius L. Forrest, Edwin Fox Chase School Frank, Anne Frankford High School Franklin Learning Center Franklin, Benjamin Franklin, Benjamin (elementary) Furness, Horace Gideon, Edward Girard Academic Music Program Girard, Stephen Gompers, Samuel Greenberg, Joseph Greenfield, Albert M. Hackett, Horatio B. Hamilton, Andrew Hancock, John Harding, Warren G. Harrington, Avery D. Hartranft, John F. Henry, Charles W. Heston, Edward High School of the Future Hill-Freedman World Academy Holme, Thomas Hopkinson, Francis Houston, Henry Howe, Julia W. Huey, Samuel B. Hunter, William H. Jackson, Andrew Jenks, A.S. Jenks, John S. Juniata Park Academy Kearny, General Phillip Kelley, William D. Kelly, John B. Kenderton School Kensington Health Sciences Academy Kensington HS for Creative & Performing Arts Kensington High School Key, Francis Scott King, Martin Luther Kirkbride, Elizabeth LaBrum, General J. Henry Lamberton, Robert Lankenau High School Lawton, Henry W. Lea, Henry C. Leeds, Morris Lincoln, Abraham Lingelbach, Anna L. Locke, Alain Loesche, William H. Logan, James Longstreth, William Lowell, James R. Ludlow, James R. Marshall, John Marshall, Thurgood Mastbaum, Jules E. Masterman, Julia R. Mayfair School McCall, General George McCloskey, John F. McClure, Alexander McDaniel, Delphaine McKinley, William McMichael, Morton Meade, General George G. Meehan, Austin Meredith, William M. Middle Years Alternative School Mifflin, Thomas Mitchell, S. Weir Moffet, John Moore, J. Hampton Morris, Robert Morrison, Andrew J. Morton, Thomas G. Motivation High School Munoz-Marin, Luis Nebinger, George W. Northeast High School Olney School Overbrook Educational Center Overbrook Elementary Overbrook High School Parkway Center City High School Parkway Northwest High School Parkway West High School Patterson, John M. Peirce, Thomas M. Penn Alexander School Penn Treaty High School Pennell, Joseph Pennypacker, Samuel Penrose School Phila. Learning Academy North Phila. Learning Academy South Philadelphia High School for Girls Philadelphia Military Academy Philadelphia Virtual Academy Pollock, Robert B. Potter-Thomas School Powel, Samuel Prince Hall School Randolph, A. Phillip Rhawnhurst School Rhoads, James Rhodes, E. Washington Richmond School Robeson, Paul Roosevelt, Theodore Rowen, William Roxborough High School Saul, Walter B. Sayre, William L. Science Leadership Academy Science Leadership Academy Middle School Science Leadership Academy at Beeber Sharswood, George W. Shawmont School Sheppard, Isaac Sheridan, Phillip Solis-Cohen, Solomon South Philadelphia High School Southwark School Spring Garden School Spruance, Gilbert Stanton, Edwin M. Stearne, Allen M. Steel, Edward Strawberry Mansion High School Sullivan, James J. Swenson Arts and Technology HS Taggart, John H. Taylor, Bayard The LINC The U School The Workshop School Tilden, William Vare-Washington School Vaux Wagner, General Louis Waring, Laura W. Washington Jr., Grover Washington, George Washington, Martha Webster, John Welsh, John West Philadelphia High School Widener Memorial School Willard, Frances Wilson, Woodrow Wright, Richard R. Ziegler, William H.
Accused Person's Name:
First
Last
Accused Person's Grade: Unknown K 1 2 3 4 5 6 7 8 9 10 11 12
Accused Person's Age:
Accused Person's Race: Unknown White/Caucasian Black/African-American Latino American Indian/Native Alaskan Asian/Pacific Islander Other
Accused Person's Sex: Accused Person 3 (if applicable) Accused Person's School: Unknown/Other Academy at Palumbo AMY Northwest Adaire, Alexander Allen, Ethan Allen, Ethel Alternative Middle Years at James Martin Anderson, Add B. Arthur, Chester A. Arts Academy at Benjamin Rush Bache-Martin School Baldi School Barry, John Barton, Clara Bartram, John Bethune, Mary M. Blaine, James G. Blankenburg, Rudolph Bodine, William W. Bregy, F. Amedee Bridesburg School Brown, Henry A. Brown, Joseph H. Bryant, William Building 21 Carnell, Laura H. Carver HS of Engineering and Science Cassidy, Lewis C. Catherine, Joseph W. Cayuga School Central High School Childs, George W. Clemente, Roberto Comegys, Benjamin B. Comly, Watson Constitution High School Conwell, Russell Cook-Wissahickon School Cooke, Jay Cramp, William Creative and Performing Arts Crossan, Kennedy C. Crossroads Accelerated Academy Crossroads @ Hunting Park Day, Anna B. de Burgos, Julia Decatur, Stephen Dick, William Disston, Hamilton Dobbins, Murrell Dobson, James Duckrey, Tanner Dunbar, Paul L. Edison, Thomas A. Edmonds, Frankin Elkin, Lewis Ellwood School Emlen, Eleanor Farrell, Louis H. Fell, D. Newlin Fels, Samuel Feltonville Intermediate School Feltonville School of Arts and Sciences Finletter, Thomas K. Fitler, Edwin H. Fitzpatrick, Aloysius L. Forrest, Edwin Fox Chase School Frank, Anne Frankford High School Franklin Learning Center Franklin, Benjamin Franklin, Benjamin (elementary) Furness, Horace Gideon, Edward Girard Academic Music Program Girard, Stephen Gompers, Samuel Greenberg, Joseph Greenfield, Albert M. Hackett, Horatio B. Hamilton, Andrew Hancock, John Harding, Warren G. Harrington, Avery D. Hartfranft, John F. Henry, Charles W. Heston, Edward High School of the Future Hill-Freedman World Academy Holme, Thomas Hopkinson, Francis Houston, Henry Howe, Julia W. Huey, Samuel B. Hunter, William H. Jackson, Andrew Jenks, A.S. Jenks, John S. Juniata Park Academy Kearny, General Phillip Kelley, William D. Kelly, John B. Kenderton School Kensington Health Sciences Academy Kensington HS for Creative & Performing Arts Kensington High School Key, Francis Scott King, Martin Luther Kirkbride, Elizabeth LaBrum, General J. Henry Lamberton, Robert Lankenau High School Lawton, Henry W. Lea, Henry C. Leeds, Morris Lincoln, Abraham Lingelbach, Anna L. Locke, Alain Loesche, William H. Logan, James Longstreth, William Lowell, James R. Ludlow, James R. Marshall, John Marshall, Thurgood Mastbaum, Jules E. Masterman, Julia R. Mayfair School McCall, General George McCloskey, John F. McClure, Alexander McDaniel, Delaplaine McKinley, William McMichael, Morton Meade, General George G. Meehan, Austin Meredith, William M. Middle Years Alternative School Mifflin, Thomas Mitchell, S. Weir Moffet, John Moore, J. Hampton Morris, Robert Morrison, Andrew J. Morton, Thomas G. Motivation High School Munoz-Marin, Luis Nebinger, George W. Northeast High School Olney School Overbrook Educational Center Overbrook Elementary Overbrook High School Parkway Center City High School Parkway Northwest High School Parkway West High School Patterson, John M. Peirce, Thomas M. Penn Alexander School Penn Treaty High School Pennell, Joseph Pennypacker, Samuel Penrose School Phila. Learning Academy North Phila. Learning Academy South Philadelphia High School for Girls Philadelphia Military Academy Philadelphia Virtual Academy Pollock, Robert B. Potter-Thomas School Powel, Samuel Prince Hall School Randolph, A. Phillip Rhawnhurst School Rhoads, James Rhodes, E. Washington Richmond School Robeson, Paul Roosevelt, Theodore Rowen, William Roxborough High School Saul, Walter B. Sayre, William L. Science Leadership Academy Science Leadership Academy Middle School Science Leadership Academy at Beeber Sharswood, George W. Shawmont School Sheppard, Isaac Sheridan, Phillip Solis-Cohen, Solomon South Philadelphia High School Southwark School Spring Garden School Spruance, Gilbert Stanton, Edwin M. Stearne, Allen M. Steel, Edward Strawberry Mansion High School Sullivan, James J. Swenson Arts and Technology HS Taggart, John H. Taylor, Bayard The LINC The U School The Workshop School Tilden, William Vare-Washington School Vaux Wagner, General Louis Waring, Laura W. Washington Jr., Grover Washington, George Washington, Martha Webster, John Welsh, John West Philadelphia High School Widener Memorial School Willard, Frances Wilson, Woodrow Wright, Richard R. Ziegler, William H.
Accused Person's Name:
First
Last
Accused Person's Grade: Unknown K 1 2 3 4 5 6 7 8 9 10 11 12
Accused Person's Age:
Accused Person's Race: Unknown White/Caucasian Black/African-American Latino American Indian/Native Alaskan Asian/Pacific Islander Other
Accused Person's Sex: Additional Accused Person(s):
(List name, school, grade, age, race, and sex if there are more accused persons)
If identity of accused person(s) is unknown, explain:
Section II. DESCRIBE THE INCIDENT When did the incident occur? - must be mm/dd/yyyy format * Required (Date)
When did the incident occur? * Required (Time)
Where did the incident occur? * Required (Location)
Schoolyard Bus Lunchroom Classroom Hallway Recess Community Internet Other
Describe the incident in detail: * Required
Do you believe the incident was based on: race ethnicity national origin gender/sex sexual orientation color disability
(Choose all that apply by holding down Ctrl)
Which statement(s) best describe what happened: * Required Any unwanted action that involves physical aggression Getting another person to hit or harm the student Teasing, name-calling, making critical remarks, or threatening, in person or by other means Demeaning and making the victim of jokes Making rude and/or threatening gestures Excluding or rejecting the student Intimidating, extorting or exploiting Electronic communication Spreading harmful rumors or gossip Sexual harassment Other
(Choose all that apply by holding down Ctrl)
Did a physical injury result from the incident? * Required No Yes, but it did not require medical attention Yes, and it required medical attention
Did a psychological injury result from the incident? * Required No Yes, but psychological services have not been sought Yes, and psychological services have been sought
Was the alleged victim absent from school as a result of the incident? * Required Yes No
If yes, how many days was the student victim absent as a result of the incident?
Witness Information Witness Name:
Witness Name:
Witness Name:
