SHS Student Incident Report Form
This form is to report alleged bullying behavior that occurred in the current school year in any of the following locations; on school property, at school sponsored activity or on a school bus. This form also used to report alleged safety issues that may arise on school property, school sponsored activity, or on a school bus. Please complete this form - when complete, it will be forwarded to the building principal.

In order for behavior to be considered bullying it has to be (A) the repeated use by one or more students of a written, oral, or electronic communication, such as cyber bullying, directed at or referring to another student attending school in the same school district, or (B) a physical act or gesture by one or more students repeatedly directed at another student attending school in the same school district, that; (1) Causes physical or emotional harm to such student or damage to such student's property, (2) places such student in reasonable fear of harm to himself or herself, or damage to his or her property, (3) creates a hostile environment at school for such student, (4) infringes on the rights of such student at school, or (5) substantially disrupts the education process or the orderly operation of a school.

Your Name:
OPTIONAL: You do not have to give your name when reporting an incident, however, you must be aware that without your name, school personnel will not have a way to contact you or talk with you in confidence. Your privacy will be respected. False reports and/or accusations will be dealt with harshly.
Your answer
I am... *
Choose one
I have reported this incident to an adult. *
If yes, whom did you report it to?
Your answer
Name of person being bullied or victimized: *
Your answer
Where did this happen? *
Date(s) and Time(s) of incident *
Your answer
Name of the person(s) doing the bullying behavior or involved in safety issue: *
Your answer
Type of behavior or safety issue: *
Choose the best description
What happened? *
Your answer
Who else saw this happen? *
Your answer
Was this the first time you witnessed an incident between the parties involved? Are you aware of any prior relationship between the students? *
Your answer
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