Bullying/Harassment Incident Report
Steps to follow for students, prior to filing the incident report. 1. Ask the person to stop the behavior/harassment (don't assume they are joking or "messing around"). 2. Tell the nearest adult, bus driver, lunchroom attendant, associate, teacher, advisor, etc. 3. If unresolved file this report and/or speak to the counselor, principal or other administrator. Faculty and Staff: 1. Speak the harasser/bully 2. Redirect the harasser/bully. 3. Follow up with student who has been bullied either directly or by filing this form.
Name(s) of person(s) who were bullied or harassed. *
Student may have fought back. They don't have to be "innocent".
Your answer
Role of person doing the bullying or harassment *
Name(s) of student(s) doing the harassment or bullying *
Your answer
Where did the incident occur? *
Name(s) of witness(s) *
Maybe passive bystanders or supporters
Your answer
Explain what happened as you saw it, or as it happened to you, or was described to you. *
Please use as much detail as possible
Your answer
How did you intervene? If you did not intervene, please describe your actions after the incident. *
If you were not present, please describe your follow-up actions.
Your answer
To your knowledge, does this action follow a pattern of behavior? *
Has the agressor behaved this way before, or has the target previously reported bullying and/or harassment?
Your answer
Please add any comments that may be relevant
Your answer
Please let us know who you are. *
Your Name: Person giving the report--Not Required
Your name is not required, and this is anonymous. However, follow-up questions would be helpful in the investigation. If you don't give your name it will be difficult to follow up
Your answer
Never submit passwords through Google Forms.
This form was created inside of Cardinal Community School District. Report Abuse - Terms of Service - Additional Terms