Smithville School Incident Report
Bullying or harassing behavior is defined as any pattern of gestures or written, electronic, or verbal communications, or any physical act or any threatening communication, or any act reasonably perceived that (1) places a student or school employee in actual and reasonable fear of harm to his or her person or damage to his or her property, or (2) creates or is certain to create a hostile environment by substantially interfering with or impairing a student's education, including by not limited to educational performance, opportunities, or benefits.

This report is to be completed by the individual making or receiving a report of alleged cyberbullying, bullying, or harassment.
The administrator will complete a printed investigative/report form when receiving a verbal or written report of alleged cyberbullying, bullying, or harassment from a student.

* It is optional to include your name and email. If included, all information will be kept confidential.
* When submitted, this form will automatically email the principal of the selected school.
Type of Report *
Person Reporting Bullying/Harassment (Optional)
Your answer
Email of Person Reporting Bullying/Harassment (Optional)
Your answer
Alleged Target Student's Name(s) & Grade(s) *
Your answer
Alleged Perpetrator's Name(s) & Grade(s) *
Your answer
Name(s) of Witness(es) to Alleged Conduct *
Your answer
Date(s) of Incident(s) *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Location(s) of Incident(s) *
Your answer
Has this incident already been reported to staff *
Description of Incident(s) or Event(s) *
Your answer
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