Looking for a School Incident Report Templates? Download it for free!

Harassment, Intimidation, And Bullying Form - Greenwich-Stow Creek Township Partnership Schools Page 2

Greenwich-Stow Creek Township Partnership Schools

Harassment, Intimidation, and Bullying Form

Indicate how you learned about the Alleged Incident:

Witness Alleged Incident

Informed by Alleged Victim

Informed by Other Person (If so, identify if student, parents, employee, or

volunteer): __________________________________________________

___________________________________________________________

Identify what harm you believe was or may have been caused by the alleged incident.

Check all that may apply:

Substantial disruption or interference with orderly operation of the school;

Substantial disruption or interference with rights of others;

Physical or emotional harm;

Insulting or demeaning;

Creates a hostile educational environment;

Interferes with student’s education;

Other (Please elaborate): ______________________________

List anyone who you know or have reason to believe may have relevant knowledge of the

alleged incident(s) (i.e., any eye witnesses or other persons with knowledge of what is

alleged to have occurred) and please indicate if the individual(s) is/are a student, parent,

staff member of other:

Name of person who received your initial verbal report (if any): ____________________

Date of your verbal report (if any): ___________________________________________

Person to whom you provided this written report: ________________________________

Signature:______________________________________________ Date:___________

(if anonymous, please place an “X” on the signature line)

Harassment, Intimidation, And Bullying Form - Greenwich-Stow Creek Township Partnership Schools Page 2