Harassment, Intimidation Bullying Incident Report Form
Harassment is defined as a continuous pattern of intentional behavior, and includes but is not limited to written, electronic,verbal, physical act, or gesture by an individual or group that is reasonably perceived to be threatening by the student-victim.In an effort to minimize this type of behavior in the school environment, which includes on school property, at a school sponsored event, on a school bus, or on an electronic device accessed on school property or at a school event, the WISD has created a process whereby a student, parent, guardian, or bystander may report instances of harassment to the school administrator for further review and investigation. Upon completion/submitting this form will be sent to the campus principal. All reported incidents of harassment are investigated, and when necessary, school administrators apply appropriate disciplinary consequences.
Have you submitted a harassment/bullying report form previously?
Reporter’s Name (OPTIONAL):
You are (relation to incident):
You are (victim or witness):
If you would like someone to contact you, please provide your phone number:
Date of Incident:
Time of Incident
Name of Victim:
Name of alleged aggressor:
Location of Incident:
School Campus (specify campus):
School Event (specify event and location):
School Bus (specify bus number):
Electronic Device (you might be asked to provide screenshots)
Please specify the location from the above location
Type of Harassment (please check all that apply):
Moderate physical contact (shoving, pushing, snatching personal property, etc.)
Severe physical contact (hitting, punching, kicking, spitting, etc.)
Stalking either in person or online
Teasing/name calling/demeaning jokes
Destruction of property
Electronic communication (texts, sexts, email, etc.)
This behavior is:
Related to student’s perceived sexual orientation or gender identity
Related to student’s religious beliefs
Related to student’s racial or cultural background
Related to student’s disability
None of the above descriptions apply to this situation
Please describe this incident and include as many details as possible:
Did a physical injury occur from this incident?
Yes, but it did not require medical attention
Yes, and it required medical attention
If it required medical attention please specify
Did the victim miss school due the incident?
If the victim missed school how many days?
Are there any additional witnesses to the alleged event?
If there are additional witnesses please provide names and grade level information. If you are not sure of the names, please describe him/her/them.
Is there any additional information that you would like to provide?
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This form was created inside of Woden ISD.