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Threat Assessment Team Form Submission
This form should be used by parents or guardians to report allegations to the school based threat assessment team. Once the form is received by the school, the principal is responsible for implementing the school district's policy and procedures.
In the event of an immediate threat - do not submit this form and contact the Bloomingdale Police Department and/or dial 9-1-1.
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* Indicates required question
Date of Submission
*
MM
/
DD
/
YYYY
Individual Completing this Form. (If you prefer to remain anonymous, leave this section blank.) Otherwise, please provide your name and relation to the individual involved in the alleged incident of and a contact phone number and email to reach you.
Your answer
Please select the school that applies to this report
*
WTB Walter T Bergen School
SRD Samuel R Donald School
MBD Martha B Day School
Unsure
Please provide the date and approximate time when this incident occurred.
Your answer
Please describe the incident in as much detail as possible (What was the incident? Who was involved? How were you made aware of the incident? How did the incident occur?)
Your answer
Specific incident location (i.e., in a specific classroom, specific hallway/location, online/via social media)
Your answer
Please provide the name of the alleged offender
Your answer
Please provide any additional information that you believe is useful in relation to this incident. (If there are pictures, posts, etc. please provide us with links where we can review them.
Your answer
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