Student Statement Report
Student Statement Report
Berea City School District
CONFIDENTIAL
Your Name
Your Name
First
Last
Today's Date
Today's Date
/
MM
/
DD
YYYY
Your Grade
9
10
11
12
Date of Incident
Date of Incident
/
MM
/
DD
YYYY
When/where did the incident take place:
List the people directly involved with the incident:
List other witnesses (students or adults):
Describe what happened:
What did you do before/during/after?
Student Signature (please type your name)