Safe School Climate Report
* Required
Person Reporting Incident (name not required)
*
Choose "Anonymous" to remain completely anonymous, and choose "Other" to report your name.
Parent
Student
Staff
Anonymous
Other:
Required
Alleged Victim Name
*
Your answer
Alleged Perpetrator Name(s)
Your answer
Potential Witnesses Names
Your answer
Date & Time of Alleged Incident
If Known
MM
/
DD
/
YYYY
Time
:
AM
PM
Where did the incident happen
*
Check all that apply
On school property
At a school-sponsored activity or event off school property and has caused significant disruption to the educational process of the school
On the school bus
On the way to/from school
Off school grounds – no educational link
In cyber-space and created a hostile environment at school for the student, infringed on the rights of the student at school or substantially disrupted the educational process of the school.
Required
Check the statement(s) that best describes what happened.
*
Check all that apply
Any bullying, harassment, intimidation that involves physical aggression
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means
Demeaning and making the victim the object of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating, extorting or exploiting
Spreading harmful or hurtful rumors or gossip
Teen dating violence
Electronic communication
Other:
Required
Summarize Incident
*
Your answer
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