Bullying/Harassment Incident Reporting Form
The Andrew Community School District is committed to providing all students and staff with a safe and civil environment in which all members of the school community are treated with dignity and respect. Bullying/harassment is any electronic, written, verbal, or physical act or conduct toward a person based on any actual or perceived trait or characteristic of the person and which creates a hostile school environment that meets one or more of the following conditions:
- Places the student in reasonable fear of harm to the student's person or property.
- Has a substantially detrimental effect on the student's physical or mental health.
- Has the effect of substantially interfering with a student's academic performance.
- Has the effect of substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.
Type of Incident *
Date of Incident *
Your answer
Person(s) you are reporting *
Your answer
Person(s) making complaint *
Your answer
Description of incident *
Your answer
Who have you reported this incident to? *
Choose all that apply:
Who are witnesses to the incident? *
Your answer
I am a *
Name *
By placing my name in this box, I agree that all of the information on this form is accurate and true to the best of my knowledge. Incidents will be followed.
Your answer
Contact information *
Address/Phone Number/etc.
Your answer
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