Incident Reporting Form

If you feel unsafe, have information about a student who feels unsafe, or witnessed an incident (bullying, sexual harassment, or harassment), you can report it here. This includes: • Bullying, sexual harassment, harassment or intimidation at school • Bullying, sexual harassment, harassment or intimidation outside of school • Incidents that have occurred on social media (FaceBook/Twitter/Instagram/Text Messaging, etc.) • Knowledge of fights, drugs, alcohol or weapons at school • Knowledge of friends who talk about hurting themselves or you have thoughts about hurting yourself

1.	Name of program* Select at least 1.
	Special Education    Child Development    Juvenile Court and Community Schools

2.	What is the name of the program location/site? *

3.	Where did the incident occur? Briefly describe where this occurred - Facebook, text, on the bus, in class, etc. *

4.	What date did the incident occur?*

5.	What time did the incident occur?*

6.	What is the name of the person who was bullying, sexual harassing, harassing, intimidating or causing harm? Please include first name, last name and grade if known. *

7.	What is the name of the person being harmed, bullied, sexually harassed, harassed or intimidated? Please include first name, last name and grade if known.*

8.	Describe what happened. Please provide as much detail and information as you can. Please list the first and last name of any witnesses.*

9.	Who are you?* Select at least 1.
	Student    Parent    Teacher    School Staff Member    Other, please specify

10.	What is your first and last name, contact phone number, and email? We are required to contact you as part of our investigation process.*