Incident Report
You may use this form to report a conflict, bullying, or other inappropriate behavior. You may fill this out for yourself (if you are the target) or for someone else if you are being an Upstander
Your First Name *
Your answer
Your Last Name *
Your answer
What Grade are you in? *
What is the name of the student (s) being targeted (first and last name)? *
Your answer
What is the grade of the student who is being targeted? *
What is the name(s) of the student(s) who was bullying or using inappropriate behavior (first and last name?) *
Your answer
What grade are they in?
I want to report (you may check more than one) *
Where did this happen? *
If this occurred during class time, which period?
If this occurred during class time, which teacher's class was it?
Your answer
What was the date that this happened? *
Your answer
What time of day did this happen *
How often is the behavior happening? *
Has only happened once
Very Often (almost daily)
How bad is the behavior? *
It is annoying
I do not want to come to school until it stops
How safe do you feel when you are at school? *
Very unsafe
Very Safe
You may choose to tell what happened in more detail
Your answer
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