Child Online Safety Report Form
Use this form to report online safety concerns involving a child. All details will help us assess and address the situation appropriately.
Reporter Full Name
*
First Name
Last Name
Reporter Contact Email
*
example@example.com
Relationship to the Child
*
Please Select
Parent or Guardian
Teacher or School Staff
Family Member
Friend
Other
Child’s Name or Identifier
*
Child’s Age or Age Range
*
Please Select
Under 7
7-10
11-13
14-17
18 or older
Unknown
Type of Online Safety Concern
*
Please Select
Cyberbullying
Inappropriate Content
Online Predation
Harassment or Threats
Privacy Violation
Other
Platform, App, or Website Involved
*
Date and Time the Incident Was Noticed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Describe What Happened
*
Immediate Action Already Taken (if any)
Submit Report
Should be Empty: