Harassment/Incident Report
Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “…adopt a policy  for the control and discipline of all children attending public school in that district, and for the  investigation of reported incidents of harassment, intimidation, bullying, or threatening  behavior.” This report form will assist districts in collecting reported incidents of such behavior.
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电子邮件地址 *
Reporting Person Information (optional)
First Name
Last Name
Relationship
Phone Number (123-456-7890)
Email
Incident Details
School Site *
Date *
年
/
月
/
日
Time *
时间
:
Room/Location *
Student Affected *
Grade *
Class
Student(s) Initiating Bullying/Harassment *
Grade *
Class
Witness
Witness
Type of Alleged Harassment
Type *
If you checked any item above and you are not getting help from the district, contact the US  Department of Education’s Office of Civil Rights to file a complaint.
Select below *
Select all spaces below that apply. Inappropriate behaviors include:
Gesture, written or verbal expression
Physical Act
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Electronic Communication (identify the component used)
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Damage of student's property
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Reasonable fear of harm to person or property
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Disrupt or interfere with school's educational mission or the education of student.
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Additional details of the incident
Physical evidence
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Was the affected student absent from school as a result of this incident?
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If you selected no, what was the reason?
How many days?
Has a complaint relevant to this incident been filed before?
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If you selected yes, where?
If you selected yes, with whom?
If you selected yes, when?
I agree that all information is accurate and true to the best of my knowledge
Electronic Signature *
Date *
年
/
月
/
日
您回复的副本将通过电子邮件发送到您提供的地址。
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