Student Incident Report Form
Please use this form to report any instances of Rude/Mean/Bullying behaviors. This form is NOT for reporting self harm or suicidal thought concerns. If you or someone you know is thinking of hurting themselves, please talk to your trusted adult or call 911.
Name of Student Reporting the Incident
You are not required to answer this question
Grade of Student Reporting the Incident
Name of other Students Involved in the Incident
Grade of Student(s) Involved the Incident
Where did the incident happen:
Brief description of the situation
Describe here WHO was involved, WHAT happened, WHERE it happened, and WHEN it happened. Be as descriptive as possible. If you are using this to report someone who is thinking of hurting themselves or you are thinking of hurting yourself, please contact a trusted adult or call 911.
Was this incident:
Rude: Someone said or did something unintentionally hurtful and it happened one time.
Mean: Someone said or did something intentionally hurtful and they did it once.
Bullying: Someone said or did something intentionally hurtful AND they keep doing it, even when you tell them to stop or you showed them you are upset.
I am reporting this incident because:
This incident happened to me.
I heard this incident happened to someone else.
I saw this incident happen to someone else.
This is the first time this has happened.
This is an ongoing problem with the same people.
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This form was created inside of DeKalb CUSD428.