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Incident Reporting Form
San Diego ISD
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* Required
Email
*
Your email
Today's Date
*
MM
/
DD
/
YYYY
First Name (Confidential)
*
Your answer
Last Name (Confidential)
*
Your answer
Relationship to alleged victim/offender (optional)
Your answer
Identify alleged bully
*
Student
Staff
Other
Required
Name of Bully(s)
*
Your answer
List alleged victim or victim's names
*
Your answer
List names of witness(s) to the incident
*
Your answer
Incident Date
*
MM
/
DD
/
YYYY
Incident Time
*
Time
:
AM
PM
Did the alleged incident occur on school property?
*
Yes
No
Did the alleged incident occur at a school sponsored activity?
*
Yes
No
Campus
*
Collins-Parr Elementary School
Bernarda Jaime Junior High School
San Diego High School
Other:
Location of the incident examples cafeteria, gym, football field etc.
*
Your answer
Types of Harassments
*
Verbal
Written
Physical
Electronic
Racial
Sexual
Religous
Other:
Required
Incident Description (all written statements must be submitted with date and signatures)
*
Your answer
Has anyone in the school helped you with this complaint?
*
Yes
No
Have you previously reported this incident?
*
Yes
No
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