Version en español
PERSON REPORTING INCIDENT:
*On what date did the incident happen?
Alleged Witness(es) (if known):
Alleged Offenders: (Please enter 'Unknown' in Last Name field if you don't know the offender's name)
*Where did the incident happen (choose all that apply)?
*Check the boxes that best describe what happened (choose all that apply):
*What did the alleged offender(s) say or do?
*Why did the harassment or initimidation (bullying) occur?
*Did a physical injury result from this incident? Please select one of the following:
*If there was a physical injury, do you think there will be permanent effects?
*Was the student victim absent from school as a result of the incident?
*If yes, how many days was the student victim absent from school as a result of the incident?
*Did a psychological injury result from this incident? Please select one of the following:
Is there any additional information you would like to provide?