Incident Report Form

GSYO does not tolerate bullying, harassment, or threatening behavior, and we take reports of such behavior seriously. All reports will be investigated by GSYO staff to ensure that GSYO continues to be a safe learning environment.
NAME OF REPORTER

We encourage you to include your name in this report. If you choose to include your name, GSYO will be better able to assist you/your child in resolving the situation and will be able to connect with you about the next steps. However, if you choose to make an anonymous report, a GSYO staff member will review the information and do their best to investigate (if appropriate) the situation.
Name of Reporter (leave blank if you wish to remain anonymous)

First NameLast Name
Are you a...*

StudentParentTeacherWitnessOther
PREFERRED METHOD OF CONTACT

If you choose to submit a non-anonymous report and GSYO finds it necessary to follow up with you, how would you like to be contacted?

Note: If you would like your report to be anonymous, please leave this section blank.
Primary Contact Name

First NameLast Name
Primary Contact is a...

StudentParentGSYO TeacherSchool Teacher/AdministratorHealthcare ProfessionalOther
Phone Number
Leave blank if you do not wish to receive a phone call
Primary Contact Email
Leave blank if you do not wish to receive an email
WHO IS INVOLVED?

We encourage you to include the name(s) of those involved, which will allow GSYO staff to investigate the situation and work for a resolution. However, if you choose not to include the names of those involved, leave the question blank, and a GSYO staff member will review the information and do their best to investigate (if appropriate) the situation described.
Name(s) of those involved
Use a comma to separate multiple names, leave question blank if you do not wish to include names
Ensemble(s) (please tell us your ensemble and/or the ensemble(s) of the student(s) involved)

Chamber PlayersCamerata OrchestraGalbraith Honor StringsEl Camino Wind OrchestraCamilla Kolchinsky OrchestraSymphony OrchestraOther
INCIDENT REPORT
What kind of behavior are you reporting?*

Harassment/Intimidation (aggressively making someone feel less than)Exclusion (purposefully making someone feel not part of the group)Physical Aggression (hitting, kicking, punching, shoving, etc.)Sexual Harassment (sexual comments, unwanted physical contact)Cyber-bullying (using social media or internet to make someone feel uncomfortable)Threatening (actions and words that purposefully make someone feel afraid)Stealing or Damaging Property (taking or damaging someone else's possessions)Other
Is this a recurring event? (Has it happened before/have there been multiple incidents?)*

YesNo
Description (Please provide a description of the incident and when it happened)*
Please describe the impact this incident has had.*
Should be Empty: