Bullying / Harassment Incident Report Form
This form should be used to report a possible incident of bullying as defined in TSMS's policy prohibiting bullying and harassment. Bullying according to school policy involves systematic and chronic inflictions of physical hurt or psychological distress on one or more student or employee. Harassment according to school policy is threatening, insulting, or dehumanizing gestures, use of data, telecommunications facilities (wireless phones, text messages), or computer software or technology (email, social networking sites, blogs, web pages), or written, verbal, or physical conduct directed against a student or employee.

This form can be filled out by any person concerned about bullying or harassment. (Please use the final 2 questions at the bottom of this form if you would like to list your needs, your concerns.)
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Your Name: (optional)
School:
Name of person being mistreated:
Name of person accused of bullying/harassment:
Date of incident
MM
/
DD
/
YYYY
Additional dates of incidents?
Where did the incident happen?
Choose the statement(s) that best describes what happened. Choose all that apply.
What did the alleged offender(s) say or do?
Was the incident related to the alleged victimized person's race, sex, or disability?
Clear selection
If yes, please give a brief explanation.
Have you reported this incident to anyone before?
Clear selection
If yes, who?
Please list any witnesses.
Thank you. This report will be followed up in a prompt manner. By completing this form, you are verifying that your statements are true and exact to the best of your knowledge. If you fear a person is in IMMEDIATE danger, please contact a trusted individual right away!
If you have concerns, please list them.
If you have needs, please list them.
Submit
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