Harassment/Incident Report
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.
The respondent's email () was recorded on submission of this form.
Reporting Person Information (optional)
First Name
Last Name
Phone Number (123-456-7890)
Incident Details
School Site *
Date *
Time *
Room/Location *
Student Affected *
Grade *
Student(s) Initiating Bullying/Harassment *
Grade *
Type of Alleged Harassment
Type *
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.
Select below *
Select all spaces below that apply. Inappropriate behaviors include:
Gesture, written or verbal expression
Physical Act
Electronic Communication (identify the component used)
Damage of student's property
Reasonable fear of harm to person or property
Disrupt or interfere with school's educational mission or the education of student.
Additional details of the incident
Physical evidence
Was the affected student absent from school as a result of this incident?
If you selected no, what was the reason?
How many days?
Has a complaint relevant to this incident been filed before?
If you selected yes, where?
If you selected yes, with whom?
If you selected yes, when?
I agree that all information is accurate and true to the best of my knowledge
Electronic Signature *
Date *
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This form was created inside of Perry Public Schools.