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Incident Form - Bullying - Westminster Community Charter School
Bullying is unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. The behavior is intentional and purposefully carried out in order to cause harm to another person or group of people.

Please us this form to inform a WCCS administrator and counselor about the bullying concern that you have. Once this referral is received, we will follow up with involved parties and also with you.

You are welcome to report bullying anonymously. If an anonymous referral is submitted, we will not be able to follow up with you, but will address the incident that has been reported.

What Students Were Involved in the Incident? (This includes, Bully, Victim, Bystanders, Observers, etc.... Include grade of students if possible)
Your answer
Check which meets the nature of the bullying incident
What happened? Describe the incident in as much detail as possible.
Your answer
When did the incident take place?
MM
/
DD
/
YYYY
Choose which meets the type of discrimination/harassment
Where did the incident take place?
Your answer
Check which meets the description of the offenders involved within the incident
Please provide any additional information that you think is important for us to be aware of.
Your Name (Optional)
Your answer
Your Role (Optional)
If you are a Westminster parent, what is the best way for us to reach you so that we can follow up with you regarding this incident? (Optional)
You may leave phone number and/or email address.
Your answer
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