School BoardBoard Members Student Board Members Meetings Meeting Agendas Meeting Minutes Current Issues Goals Policies & District Administrative Regulations Election Information Legislative Advocacy |
STUDENTS Bullying Bullying /Harassment Incident Report Form Or Witness Statement
Name of Person Bullied or Harassed: _____________________________________________________________
Names of Alleged Bully(ies) or Harassers:
_________________________________ __________________________________
_________________________________ __________________________________
Where Did the Incident Happen? Choose all that apply:
_____ Classroom ______ Restroom ______ Bus _____ Cafeteria ______ Gym ______ To/From School _____ Hallway ______ Locker Room ______ School Sponsored Activity or Event off School Property
Describe in detail exactly what happened:
Physical evidence related to the incident to include physical marks, email, websites, video/audio tapes, photos or other evidence:
Names of Witnesses:
______________________________________ _____________________________________
______________________________________ _____________________________________
Other Information:
I AGREE THAT ALL THE INFORMATION ON THIS FORM IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE:
____________________________________________ _____________________________ Signature of Victim Date
____________________________________________ _____________________________ Signature of Staff Date
Person filling out form Name:___________________________ Relationship to person bullied: Self_________ Parent ________ Witness ________
8/10
|
