Southside Elementary School Incident Report
Bullying and/or Intimidation is defined as: Repeated intentional behavior by an individual with power over the victim or victims. Such behavior may include, physical, verbal, written or electronic communication or conduct of a belittling or browbeating nature.
(This is a required question and will be kept confidential)
Contact info (home phone/cell/email/homeroom
Name of adult(s) you've already contacted
Name of Accused
(Again this is confidential)
Please check the box that best describes what the accused did. Please choose all that apply.
Physical: Hitting, kicking, shoving, spitting, etc
Teasing, naming calling, put downs, criticizing, jokes
Threatening in person, by phone, by e-mail, etc.
Excluding or rejecting the student
Getting another person to hit or harm the student
Property issues. (hiding, damaging, taking)
Making rude and/or threatening gestures
Spreading harmful rumors or gossip
Description of current incident.
If I were watching it on a video, what exactly would I see?
Where did the incident happen?
If you marked other on the previous question please explain below.
Any previous incidents
(Again, please be as specific as possible)
Please list any witness if there were any.
How did you respond to the incident?
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