Harassment, Intimidation And Bullying Incident Reporting Form
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1Harassment, Intimidation and Bullying Incident Reporting Form
Name of reporting person (optional): ___________________________________________ School: ____________________ Date: ___________
Anonymous
Confidential
Non-confidential
Individuals may file a report without
Individuals may ask that their identities be
Complainants agreeing to make their
revealing their identity. No disciplinary
kept secret from the accused and other
complaint non-confidential will be informed
action will be taken against an alleged
students. Like anonymous reports, no
that due process requirements may require
aggressor based solely on an anonymous
disciplinary action will be taken against an
that the district release all of the
report. Possible responses to an
alleged aggressor based solely on a
information that it has regarding the
anonymous report include enhanced
confidential report.
complaint to any individuals involved in the
monitoring of specific locations at certain
incident, but that even then, information will
times of day or increased monitoring of
still be restricted to those with a need to
specific students or staff.
know, both during and after the
investigation. The district will, however,
fully implement the anti-retaliation provision
of this policy and procedure to protect
complainants and witnesses.
Targeted person(s): ______________________________________________________________________________________________________
Your email address (optional): ____________________________________________ Your phone number (optional): ______________________
Name of school adult you’ve already told (if any): ______________________________________________________________________________
Name(s) of bullies (if known) or other identifiers (like physical description or class individual may have):
______________________________________________________________________________________________________________________
On what dates and times did the incident(s) happen (if known)? ___________________________________________________________________
Where did the incident happen? Please choose all that apply.
Classroom
Hallway
Restroom
Playground
Locker room
Lunchroom
Sport field
Parking lot
School bus
School activity
On the way to/from school
Off school property
Internet
Cell phone
Other: _______________________
Please check the box that best describes what the bully did. Please choose all that apply.
Sharing inappropriate drawings/cartoons/photographs/images/notes.
Making rude, threatening and/or critical gestures or remarks.
Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)
Getting another person to hit or harm the individual.
Spreading harmful rumors or gossip.
Making the individual fearful, demanding money or exploiting.
Hitting, kicking, shoving, spitting, hair pulling or throwing something at
Putting the individual down and making the individual a target of
the individual.
jokes, teasing, or name calling.
Making unwelcomed sexual advances, requests for sexual favors,
Excluding or rejecting the individual—motivated by race, color,
sexually motivated physical contact or other verbal or physical conduct
religion, ancestry, national origin, cultural, gender, socio-economic
of a sexual nature.
status, sexual orientation including gender expression or identity,
mental or physical disability or other distinguishing characteristics.
Other: ________________________________________________________________________________________________________________
Why do you think the harassment, intimidation or bullying occurred? _______________________________________________________________
______________________________________________________________________________________________________________________
Were there any witnesses? No Yes. If yes, please provide their names: _______________________________________________________
______________________________________________________________________________________________________________________
Did a physical injury result from this incident? No Yes. If yes, please describe: _________________________________________________
______________________________________________________________________________________________________________________
Was the target person absent from school as a result of the incident? No Yes. If yes, please describe:_______________________________
______________________________________________________________________________________________________________________
Is there any additional information? _________________________________________________________________________________________
For office use only
Date received: ___________
Report received by: ________________________________ Name of parent/guardian contacted: ________________________
Action taken: _______________________________________________________________________________________________________________________
Check one: Resolved Unresolved
Referred to: _______________________________________________________________________________
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