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
Student to Student
Student to Staff
Staff to Student
Date of Incident
Person(s) you are reporting
Person(s) making complaint
Description of incident
Who have you reported this incident to?
Choose all that apply:
Who are witnesses to the incident?
I am a
Choose from the list:
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.
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