School Incident Report

Please fill this form out to the best of your ability. Sagamore Institute takes any incident involving an exchange teacher seriously and needs the most accurate and complete information to take any necessary steps to address the incident. We are required to report certain types of incidents to the US State Department. This form is very important to help us document your concerns. Thank you!

Today's Date

Teacher First and Last Name

School Name

First and last name of the School Official completing this form

Email Address of the School Official completing this form

Phone number of the School Official completing this form

Date Incident Occurred

What was the nature of the incident? Check all that apply.

Incident involving Criminal Justice System	Employment and Contract Issues
Unsuitable Working Conditions	Serious Mental Health Concerns
Substance Abuse	Serious Illness or Injury
Sexually-Related Abuse	Foreign Government or Embassy Intervention
Situation that impacts Teacher Safety	Sponsor Violations
Other

Please write a brief description of the incident.

To whom has this incident been reported (Principal, HR office, police, etc.)?

What steps have you or others taken to resolve the incident?

Contact Information