HARASSMENT/BULLYING INCIDENT REPORT
Incident Date & Time
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Month
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Day
Year
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Hour Minutes
AM
PM
AM/PM Option
Your Name:
Where were you when this incident happened?
Student(s) Initiating Bullying/Harassment
Type Of Harassment Alleged:
Please Select
Racial
Sexual
Religious
Other
Check all spaces below that apply:
Name Calling
Stalking
Inappropriate Gesturing
Staring/Leering
Writing/Graffiti
Threatening
Taunting/Ridiculing
Inappropriate Touching
Spitting
Demeaning Comments
Stealing
Damaging Property
Shoving/Pushing
Hitting/Kicking
Flashing a Weapon
Intimidation/Extortion
Other
Describe the incident:
Witnesses Present
Do you need assistance?
I need to speak to a counselor.
I need to speak to the principal.
I need help with my anger.
I need an adult to monitor this area.
I would like an adult to keep this person away from me.
I would like an adult to stop this bullying.
Other
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