Harassment, Intimidation Bullying Incident Report Form
Woden Elementary
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.
Reporter Information
Have you submitted a harassment/bullying report form previously?
Reporter’s Name (OPTIONAL):
Your answer
You are (relation to incident):
You are (victim or witness):
If you would like someone to contact you, please provide your phone number:
Your answer
Incident Information:
Date of Incident:
MM
/
DD
/
YYYY
Time of Incident
Time
:
Name of Victim:
Your answer
Name of alleged aggressor:
Your answer
Location of Incident:
Please specify the location from the above location
Your answer
Type of Harassment (please check all that apply):
This behavior is:
Please describe this incident and include as many details as possible:
Your answer
Did a physical injury occur from this incident?
If it required medical attention please specify
Your answer
Did the victim miss school due the incident?
If the victim missed school how many days?
Your answer
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.
Your answer
Is there any additional information that you would like to provide?
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Woden ISD. Report Abuse