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.
* Required
Email address
*
Your email
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
*
Time
:
AM
PM
Person Reporting Complaint
*
Your answer
Relationship to complainant
*
Mother
Father
Sibling
Other:
If responsible for the education of the victim, please indicate the best way to contact you.
Your answer
Name of Victim
*
Your answer
Grade of Victim
*
PK
K
1
2
3
4
5
6
7
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10
11
12
Other:
Name of Victim #2 (if so)
Your answer
Grade of Victim #2 (if so)
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Other:
Clear selection
Name of Victim #3 (if so)
Your answer
Grade of Victim #3 (if so)
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Other:
Clear selection
Name of Student Initiating Behavior Incident
*
Your answer
Grade of Student Initiating Behavior Incident
*
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Other:
Name of #2 (if so) Student Initiating Behavior Incident
Your answer
Grade of #2 (if so) Student Initiating Behavior Incident
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Other:
Clear selection
Name of #3 (if so) Student Initiating Behavior Incident
Your answer
Grade of #3 (if so) Student Initiating Behavior Incident
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Other:
Clear selection
Name of Witness
Your answer
Name of Witness
Your answer
Name of Witness
Your answer
Where did incident happen? Check all that apply.
*
Hallway
Restroom
Bus
Recess
Classroom with Teacher
Classroom without Teacher
Outside Waiting Area
Lunchroom
Cafeteria
On Way to/from School
Parking Lot
Locker Room
Other:
Required
Mark the statement that describes what happened: Check all that apply.
*
Name Calling
Taunting/Ridiculing
Graffiti/Writing
Inappropriate Touching
Excluding/Rejecting
Spreading Rumors/Gossip
Demeaning Comments
Stealing/Damaging Property
Shoving/Hitting/Kicking
Threatening
Inappropriate Gesturing
Intimidating/Extorting/Exploiting
Cyber Bullying (Social Networking, Text, Email)
Other:
Required
When did the incident occur?
*
Before School
During School
After School
Describe the incident:
*
Your answer
Specific Concerns: Check all that apply.
*
Physical Injury
Severity of Bullying
Damaging Clothing
Emotional Needs
Fear of Retaliation
Transportation Needs
Other:
Required
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