Behavior Incident Report Form

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Stratford Middle and High School

Email *

Date of Incident *

YYYY

Time of Incident *

Time

Is this a repeat incident? *

Yes

If yes, explain:

Location of the incident (Check all that apply) *

Hallway

Restroom

Classroom

Gym

Locker room

Lunch Room

Bus

Parking Lot

Commons

Library

School Event

Text/Phone/Internet/ Social Media

Other:

Required

Name of victim(s) *

Name of student(s) being reported *

Name of Witness(es)

Type of Reported Behavior *

Verbal (ex: intimidating language, name-calling, sexist or racist remarks)

Physical (ex: assault, hitting, kicking, destruction of property, theft)

Indirect (ex. spreading rumors, cyberbullying, social exclusion)

If physical

Yes

Result in injury?

Medical assistance needed?

Reported to police?

Clear selection

Reported Behaviors *

Shoved/Pushed Hit

Kicked, Punched

Threatened

Stole/Damaged Possessions

Excluded

Taunted/Ridiculed

Writing/Graffiti

Told Lies/False Rumors

Staring/Leering

Intimidation

Demeaning Comments

Inappropriate touching

Racial harassment

Sexual harassment

Religious harassment

Disability based harassment

Required

Describe the incident *

Any physical evidence? (Attach if possible)

Reported by (Name, First & Last) *

Reported by *

Student

Staff member

Parent

Other

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