Juan Soria School Bullying and Harassment Incident Reporting Form
The Oxnard School District and Juan Lagunas Soria School are committed to providing all students and staff with a safe and civil environment in which all members of the school community are treated with dignity and respect. Bullying and/or harassment is any electronic, written, verbal, or physical act or conduct toward a person based on any actual or perceived trait or characteristic of the person and which creates a hostile school environment that meets one or more of the following conditions:
- Places the student in reasonable fear of harm to the student's person or property.
- Has a substantially detrimental effect on the student's physical or mental health.
- Has the effect of substantially interfering with a student's academic performance.
- Has the effect of substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.

Please complete the form below to report any type of bullying or harassment.

Type of incident *
Date of incident *
Your answer
Alleged Offenders (Who did the bullying) *
Your answer
Complainant(s) - (Who is being bullied) *
Your answer
Please describe the incident that occurred. Be sure to include as many details as possible. *
Your answer
Who are the witnesses to the incident? *
Your answer
Who have you reported this incident to? Check all that appy *
Required
I am a *
Required
Your Name *
Your answer
Contact Information - (i.e; teacher's name address, phone number, , etc.) *
Your answer
*
Required
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