Stanwood-Camano School District Reporting Harrassment Intimidation and Bullying
Please remember to press the submit button at the bottom of the form when complete. Each incident will require a new form to be submitted.

You may also report unresolved or persistent harassment by contacting an administrator, staff member or counselor at the targeted student's school site or contact the Stanwood-Camano School District's Harassment, Intimidation/Bullying Officer Dr. Lloy Schaaf, 360-629-1237 or email at lschaaf@stanwood.wednet.edu.

Email address
NAME OF TARGETED STUDENT
Last, First
Your answer
NAME OF PERSON COMPLETING FORM
Last, First
Your answer
YOUR EMAIL ADDRESS
Your answer
YOUR PHONE NUMBER
Your answer
NAME OF SCHOOL ADULT THAT YOU HAVE ALREADY CONTACTED
(If any)
Your answer
NAME(S) OF OFFENDER
(If known)
Your answer
ON WHAT DATES DID THE INCIDENT(S) HAPPEN
(If known)
MM
/
DD
/
YYYY
SCHOOL SITE WHERE INCIDENT TOOK PLACE
WHERE DID THE INCIDENT HAPPEN
(Mark all that apply)
PLEASE CHECK THE BOX THAT BEST DESCRIBES WHAT THE OFFENDER DID
(Please choose all that apply)
WERE THERE ANY WITNESSES
(If yes, please provide names)
Your answer
DID A PHYSICAL INJURY RESULT FROM THIS INCIDENT
(If yes, please describe)
WAS THE TARGETED STUDENT ABSENT FROM THIS INCIDENT
(If other please describe)
IS THERE ANY ADDITIONAL INFORMATION
Your answer
ADMINISTRATIVE RESPONSE
(this field is for School Administrators only)
Your answer
FOR OFFICE USE ONLY
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