BHSC Safety Alert Form

1
Email* This field is required.
example@example.com
2
Location or School of Concern* This field is required.
Please Select
Borden Elementary
Borden Jr/Sr High
Henryville Elementary
Henryville Jr/Sr High
Administration Office
3
Date and Time of Concern* This field is required.
Date
Year
Month
Day
1
2
3
4
5
6
7
8
9
10
11
12
Hour
00
10
20
30
40
50
Minutes
AM
AM
PM
4
Person(s) Involved in Safety Situation* This field is required.
5
Brief Description* This field is required.
Huge
Large
Normal
Small
Ok
Ok
6
Phone NumberOptional
Area Code
Phone Number
7
I certify that the information I am providing is accurate to the best of my knowledge, and that reporting a false complaint is subject to criminal prosecution.* This field is required.
Agree
Should be Empty: