Behavior Incident Report Form
Glenwood Community School District

Please complete the form below:

Peer Conflict:
Conflict between peers is a part of growing up. Sometimes children disagree and can’t solve their own problems. They may say mean things or even hurt each other. In peer conflict children:
• Play together and have equal power
• Are both equally upset, interested in the same outcome, and able to work things out

Mean Behavior:
Youth may try out behaviors to assert themselves i.e. making fun of others, leaving others out, or becoming physical. Adults can help by:
• Quickly and firmly stop the behavior
• Let youth know they are hurtful, and re-direct them to positive behaviors

If your situation includes the following it may be a bullying situation:

Bullying is a serious behavior that includes three features:
1. Power Imbalance – one child clearly has power over the other and the victim is unable to effectively
defend him/herself
2. Intention to harm – purpose of bullying is to harm or hurt the other
3. Repeated over time – bullying continues over time and gets worse with repetition

Your email address will be recorded when you submit this form.
Email address *
Date of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Person Reporting Complaint *
Relationship to complainant *
If responsible for the education of the victim, please indicate the best way to contact you.
Name of Victim *
Grade of Victim *
Name of Victim #2 (if so)
Grade of Victim #2 (if so)
Name of Victim #3 (if so)
Grade of Victim #3 (if so)
Name of Student Initiating Behavior Incident *
Grade of Student Initiating Behavior Incident *
Name of #2 (if so) Student Initiating Behavior Incident
Grade of #2 (if so) Student Initiating Behavior Incident
Name of #3 (if so) Student Initiating Behavior Incident
Grade of #3 (if so) Student Initiating Behavior Incident
Name of Witness
Name of Witness
Name of Witness
Where did incident happen? Check all that apply. *
Required
Mark the statement that describes what happened: Check all that apply. *
Required
When did the incident occur? *
Describe the incident: *
Specific Concerns: Check all that apply. *
Required
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