Fillable Bullying/Harassment Incident Report Form Reporting Person Information (optional) (Oklahoma)

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Bullying/Harassment Incident Report Form Reporting Person Information (optional) (Oklahoma)

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The Bullying/Harassment Incident Report Form Reporting Person Information (optional) (Oklahoma) form is 2 pages long and contains:

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  • 47 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

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Bullying/Harassment Incident Report Form
Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “…adopt a policy
for the control and discipline of all children attending public school in that district, and for the
investigation of reported incidents of harassment, intimidation, bullying, or threatening
behavior.” This report form will assist districts in collecting reported incidents of such behavior.
Reporting Person Information (optional)
Name: _______________________________________ Relationship: _____________________
Telephone: ____________________ E-Mail: _________________________________________
Incident Details
School Site: ___________________________________________________________________
Date: ____________________ Time: _________________ Room/Location: ________________
Student Affected:
____________________________________ Grade: _____ Class: ________________
Student(s) Initiating Bullying/Harassment:
____________________________________ Grade: _____ Class: ________________
____________________________________ Grade: _____ Class: ________________
Witness: ______________________________________________________________________
Witness: ______________________________________________________________________
Type of Alleged Harassment
Racial Sexual Religious Other__________________________________
If you checked any item above and you are not getting help from the district, contact the US
Department of Education’s Office of Civil Rights to file a complaint.
Yes, this is a repeated offence. No, this is a one-time incident.
Check all spaces below that apply. Inappropriate behaviors include:
Gesture, written, or verbal expression
Verbal fight
Written or verbal threat
Written note
Written or verbal rumors
Seclusion
Embarrassing the student
Other: ____________________________
Physical Act
Physical fight
Physical injuries
Other: ____________________________
Electronic communication
Identify the component used:
Cell phone
Audio or visual image
Instant message/email
Gaming
Social Networking
Blog
Other: ____________________________
Damage of student’s property
Property damage
Stolen or missing property
Other: ____________________________
Reasonable fear of harm to person or property
Fear of harm to person
Fear of harm to property
Other: ____________________________
Disrupt or interfere with school’s educational
mission or the education of student.
Changes in attendance: absences, tardies
Missing classes/parts of school day
Changes in grades
Changes in participation of school
activities
Avoidance of elements: lunch, bus, recess
Other: ____________________________
Additional details of the incident:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Physical evidence: Graffiti Notes E-mail Web sites_______________________
Video/audiotape Other____________________________________
Was the affected student absent from school as a result of this incident? Yes No
What was the reason? ____________________________________________________________
How many days? _______________________________________________________________
Has a complaint relevant to this incident been filed before?
Where:____________________ With Whom: ______________ When: ____________________
I agree that all of the information is accurate and true to the best of my
knowledge.
Signature (optional): ______________________________________ Date: _________________
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BullyingHarassment Incident Report Form Reporting Person Information (optional) (Oklahoma)

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Completed 21 January 2022

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