Role of Person Reporting the Incident  
Phone Number
Name of Targeted Student (Student being Bullied, Harassed, or Discriminated against) *
Name(s) of alleged offender(s) *
Date, Time, and Location of Incident  *
What was your involvement in the incident?  *
Where did the incident happen? (Check ALL that apply) *
Type of incident (Check ALL that apply) *
Who was involved in the incident? (Part One) *
Name who was involved in the incident (Part Two)
Describe the nature of the incident. What happened? 
(Be as SPECIFIC as possible) ~ What did the alleged offender say or do? Include any copies of text messages, emails, etc, if possible! 
If there were any adults in the area during the incident, who were they? and what did they do in response to the incident?  *
Type of Bias Involved (Check ALL that apply) *
Name(s) of others who may have witnessed the incident: *
Was the student absent from school as a result of the incident?  *
What were the number of days that the student was absent DUE to the incident?
Describe the impact the incident has had on the student (target):  *
Does the situation continue to occur?  *
Disciplinary Action Taken (FACULTY ONLY):
Internal Comments (FACULTY ONLY):
Is it a Material Incident? (FACULTY ONLY):
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