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Student at Brown Elementary School
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Victim
Witness
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Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Not a current student
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Classroom
Hallway
Bus
Cafeteria
Off School Property
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Yes
No
Maybe
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Minor, but unacceptable
Major incident
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6
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One time incident
Every day
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5
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Yes
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Yes
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Message for respondents
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I am a:
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During this incident I was a:
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james milian What is your name? (optional)
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What grade are you in? (optional)
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zainab alli
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well zaniab is rude she called me f*CK
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Where did this incident take place?
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Please describe the incident.
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Were there witnesses to this incident?
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What are the names of the witnesses? (optional)no
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Please rate the severity of this incident from your perspective, 1 being minor incident but unacceptable to 5 being major incident, could result in retaliation or violence.
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Please describe the frequency with which this type of incident occurs.
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How do you feel about this incident or person? (Examples: they are annoying, I hate them, I want to hurt them, they don’t make me mad I just want it to stop…etc)
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Did this or other incidents make you feel like harming yourself or others?
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Would you like to speak with a counselor? If yes, please add your name above.
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What else would you like for us to know about this incident?
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