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Harassment, Intimidation, & Bullying Written Incident Report
(Staff: this form is to be completed & returned to the Principal within 2 days of verbal report)
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Name of person making the report
(report may be anonymous)
Your answer
Are you: (not required)
Employee
Student
Parent
Other:
Clear selection
Name and grade of Alleged Victim(s):
Your answer
I believe that I witnessed bullying/or I am the alleged victim of bullying/or I have reasonable belief bullying is occurring in the following form(s) based upon an actual or perceived characteristic.
Race
Color
Religion
Ancestry
National Origin
Gender
Sexual Orientation
Gender Identity and Expression
Mental or Physical Disbility
Other:
Type of Bullying:
Physical
Verbal
Gesture
Written
Electronic
Name and grade of the person(s) that are engaging in the alleged bullying behaviors:
Your answer
Date and approximate time of the incident:
MM
/
DD
/
YYYY
Time
:
AM
PM
Location of the incident(s)
On School Property
School Sponsored Funtion
Off School Grounds
School Bus
Were there any witnesses to the incident? List the names of any/all potential witnesses:
Your answer
Other Comments/Relevant Information:
Your answer
Describe, to the best of your ability, the incident of harassment, intimidation, and/or bullying. Be certain to use specific details related to the incident including all names of those involved.
Your answer
Describe any educational disruptions and/or physical or emotional harm which occurred as a result of the incident:
Your answer
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