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HARASSMENT/BULLYING INCIDENT REPORT FORM

 

 

Date:                                                 Time:                                             Room/Location:                                                                

 

Student(s) Initiating Bullying/Harassment:

 

                                                                                                                           Grade:                            Class:                                   

 

                                                                                                                           Grade:                            Class:                                   

 

Student(s) Affected:

 

                                                                                                                           Grade:                            Class:                                   

 

                                                                                                                           Grade:                            Class:                                   

 

Type of Harassment Alleged:

 

Racial               Sexual                    Religious                    Other                                                                                                        

 

Check all spaces below that apply.  Adult stated or identified inappropriate behaviors as:

 

           Name Calling                                                                      Spitting

           Stalking                                                                                Demeaning Comments

           Inappropriate Gesturing                                                    Stealing

           Staring/Leering                                                                    Damaging Property

           Writing/Graffiti                                                                   Shoving/Pushing

           Threatening                                                                         Hitting/Kicking

           Taunting/Ridiculing                                                           Flashing a Weapon

           Inappropriate Touching                                                    Intimidation/Extortion

           Other                                                                                                                                                                                            

 

Describe the incident:

 

                                                                                                                                                                                                                 

 

                                                                                                                                                                                                                 

 

Witnesses Present:                                                                                                                                                                                

 

Physical evidence:  Graffiti _____ Notes _____ E-mail _____ Web sites _____ Video/audio tape _____

                                    Other                                                                                                                                                                   

 

Staff signature                                                                                                                                                                                      

 

Parent(s) contacted:  Date                                                            Time                                                                                             

 

Administrative response taken: