Incident/Harassment Report Form

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This form is designed to allow students to submit details about incidents that have occurred during the school day that are interfering with their educational progress.

This form can be used to report: lost or stolen items; witness to bullying/harassment; witness to a crime; concerns about a classmate and/or friend; as well as other incidents.

We are hoping that more students will feel comfortable completing this form if they can do so outside of our offices.

You may fill this out anonymously or with your name. All reports received are taken seriously, are confidential and will be followed-up on.

	Your Name(optional):

	Grade (optional):

	Date of Completion of Form:
	mm/dd/yyyy

	Description of Bullying Incident(s)* Please be speciic with names, dates, grades, and events

	Student Witness(es): Please indicate name(s) and grade(s)

	Faculty/Staff Witness(es):

	Have you reported this before to the school?
	Have you reported this before to the school? Yes No

	If yes to above, when?
	mm/dd/yyyy

	Have you discussed this with your parent(s)/guardian(s)?
	Have you discussed this with your parent(s)/guardian(s)? Yes No

	Would you be interested in talking with your guidance counselor?
	Would you be interested in talking with your guidance counselor? Yes No

	Would you be interested in talking with your principal?
	Would you be interested in talking with your principal? Yes No

	Would you be comfortable with us calling home to talk to your parent(s)/guardian(s)?
	Would you be comfortable with us calling home to talk to your parent(s)/guardian(s)? Yes No

	Would you be comfortable with us talking to the student and/or faculty/staff witnesses listed?
	Would you be comfortable with us talking to the student and/or faculty/staff witnesses listed? Yes No