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: