Student & Parent Anonymous Reporting

Bullying Incidents or Other Disciplinary Concerns at Xavier Academy

If you are experiencing a problem with bullying at Xavier Academy or have other discipline-related concerns regarding our school, leave your concern below for the school administration. You may submit this form anonymously; however, if you would like someone to follow up with you personally, then be sure to leave your information at the bottom of this form.

In terms of your concern, please be as specific as possible. Leaving dates, times, locations, and any other specific information may be critical to resolving your issue quickly, so please be sure to complete those sections thoroughly.

All messages will be taken seriously and will be worked on promptly. If you are experiencing a serious problem that needs immediate attention, you are urged to tell an administrator, teacher, or other trusted adult as soon as possible.

IF THIS IS AN EMERGENCY, PLEASE CALL 911

What happened?

When was the last time this occured?

Where is the problem occurring? (At School, online, in neighborhood, other )

Who is directly involved in this problem?

Are there other people we should talk to about this (witness, students who know about it, parents, etc…)?

What else might helpful for us to know?

We would like to privately follow up with your concerns and hope that you will choose to leave your name and grade level below. If you decide to stay anonymous then please remain confident that we will fully investigate your concern.

Name

Grade Level

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