Role of person reporting incident (Check one)
Student Target Student (witness) Parent/Guardian Staff Member Other
Phone:________________Email:_______________________________________________________
Name of target: (student being bullied, harassed, or discriminated against)
___________________________________________________________________________________
Names of alleged
offender(s):__________________________________________________________________________
Date(s) and time(s) of
Incident(s): _________________________________________________________________________
What was your involvement in the incident?
I was directly involved in the incident I observed the incident I heard about the incident
Where did the incident happen? (Check all that apply)
On school property Cafeteria On a school bus
Classroom Gym Off school property
Hallway Locker Room Electronic Communication
Bathroom At a school function Other (describe):
________________________
Type of incident (Check all that apply)
Physical contact (kicking, punching, spitting, tripping, pushing, taking belongings)
Verbal threats (gossip, name-calling, put-down, teasing, being mean, taunting, making threats)
Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation)
Abuse (actions or statements that put an individual in fear of bodily harm)
Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures (sexting))
Other (describe): ___________________________________________________________________
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