2020-2021 - Bullying Incident Report

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

Bullying is unwanted, aggressive behavior among school aged children that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. The behavior is intentional and purposefully carried out in order to cause harm to another person or group of people.

Please use this form to inform a WCCS administrator and counselor about the bullying concern that you have. Once this referral is received, we will follow up with involved parties and also with you.

You are welcome to report bullying anonymously. If an anonymous referral is submitted, we will not be able to follow up with you, but will address the incident that has been reported.

Email *

What students were involved in the incident? (This includes, Bully, Victim, Bystanders, Observers, etc.... Include grade of students if possible)

Which of the following describes the reason for the bullying?

National Origin

Color

Religion

Religious Practice

Disability

Gender

Sexual Orientation

Sex

Weight

Other:

Clear selection

What happened? Describe the incident in as much detail as possible. *

When did the incident take place? *

YYYY

Which statement below best describes the incident?

Involved intimidation or abuse but no verbal threat or physical contact

Involved verbal threat but no physical contact

Involved physical contact but no verbal threat

Involved both verbal threat and physical contact

Clear selection

Where did the incident take place?

Your Name (Optional)

Your Role (Optional)

Westminster Student

Westminster Parent

Westminster Staff Member

If you are a Westminster parent, what is the best way for us to reach you so that we can follow up with you regarding this incident? (Optional)

You may leave phone number and/or email address.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Westminster Community Charter School. Report Abuse

Forms