Harassment, Intimidation Bullying Incident Report Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Woden High School

Harassment is defined as a continuous pattern of intentional behavior, and includes but is not limited to written, electronic,verbal, physical act, or gesture by an individual or group that is reasonably perceived to be threatening by the student-victim.In an effort to minimize this type of behavior in the school environment, which includes on school property, at a school sponsored event, on a school bus, or on an electronic device accessed on school property or at a school event, the WISD has created a process whereby a student, parent, guardian, or bystander may report instances of harassment to the school administrator for further review and investigation. Upon completion/submitting this form will be sent to the campus principal. All reported incidents of harassment are investigated, and when necessary, school administrators apply appropriate disciplinary consequences.

Reporter Information

Have you submitted a harassment/bullying report form previously?

Yes

Clear selection

Reporter’s Name (OPTIONAL):

You are (relation to incident):

Student

parent/Guardian

Relative

School Staff

Other:

Clear selection

You are (victim or witness):

Victim

Witness/Bystander

Other:

Clear selection

If you would like someone to contact you, please provide your phone number:

Incident Information:

Date of Incident:

YYYY

Time of Incident

Time

Name of Victim:

Name of alleged aggressor:

Location of Incident:

School Campus (specify campus):

School Event (specify event and location):

School Bus (specify bus number):

Electronic Device (you might be asked to provide screenshots)

Other:

Clear selection

Please specify the location from the above location

Type of Harassment (please check all that apply):

Moderate physical contact (shoving, pushing, snatching personal property, etc.)

Severe physical contact (hitting, punching, kicking, spitting, etc.)

Stalking either in person or online

Teasing/name calling/demeaning jokes

Verbal intimidation

Inappropriate gesturing

Theft

Exclusion/rejection

Destruction of property

Sexual contact

Verbal harassment

Spreading rumors

Threats

Electronic communication (texts, sexts, email, etc.)

Public humiliation/ridicule

Cyberbullying/cyberharassment/trolling

Other:

This behavior is:

Related to student’s perceived sexual orientation or gender identity

Related to student’s religious beliefs

Related to student’s racial or cultural background

Related to student’s disability

None of the above descriptions apply to this situation

Other:

Clear selection

Please describe this incident and include as many details as possible:

Did a physical injury occur from this incident?

Yes, but it did not require medical attention

Yes, and it required medical attention

Clear selection

If it required medical attention please specify

Did the victim miss school due the incident?

Yes

Clear selection

If the victim missed school how many days?

Are there any additional witnesses to the alleged event?

Yes

Clear selection

If there are additional witnesses please provide names and grade level information. If you are not sure of the names, please describe him/her/them.

Is there any additional information that you would like to provide?

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Woden ISD. Report Abuse

Forms