Incident Report Form
Use this form to report a situation that you felt you were bullied, harassed or discriminated against.
Today's Date: *
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Person Filling Out This Form: *
Name of Person Filling Out This Form: *
Your answer
Phone Number (s) of Person Filling Out This Form: *
Your answer
The Basis of the Actual or Perceived Bullying Harassment or Discrimination is: *
Required
Name(s) of Individuals Involved: *
Your answer
Is the Person(s) involved a: *
Required
Date of the Alleged Incident(s): *
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Where Did the Incident(s) Take Place?: *
Your answer
Explain What Happened: *
Your answer
Were There Any Witnesses?: *
If Yes, Please List the Names of the Individuals:
Your answer
Has the Incident Been Previously Reported?: *
If Yes, When and to Whom?:
Your answer
I CERTIFY THAT ALL STATEMENTS ON THIS FORM ARE ACCURATE AND TRUE TO THE BEST OF MY ABILITIES: *
Required
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