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Bullying/Harassment Incident Form
Please fill this form out with as much detail as you can. Once completed, this form will then be sent to the Granton Area School District Student Services Team for review and incident management.
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Full Name of Person Reporting
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Your answer
Person who is being rude, mean or bullying you
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Your answer
Date of Incident
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MM
/
DD
/
YYYY
Grade Level
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Your answer
Location(s) of Incident
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Your answer
Rude, Mean, Conflict or Bullying? Please select the option that best describes the incident.
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Rude: disrespectful, impolite or inappropriate behavior others do not like.
Mean: unplanned, saying or doing something disrespectful on purpose that hurts the other person's feelings.
Conflict: two-sided disagreement, both people are being disrespectful, there is equal power and they are equally upset.
Bullying: when someone is mean on purpose, is one-sided and typically happens more than once. There is an imbalance of power and one person is being mean on purpose while the other person is staying respectful.
Is it one-sided or two-sided?
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One-sided
Two-sided
I don't know
Did it happen more than once?
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Yes
No
I don't know
Do you think they did it on purpose?
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Yes
No
I don't know
Were they told to stop?
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Yes
No
Who was involved?
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Your answer
In your own words, describe exactly what happened. Include what you said and did, as well as what they said and did and when this happened.
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Your answer
Witnesses: List the names of any people who may. have heard or seen the incident.
Your answer
This complaint is based upon my honest belief that the information I have provided in this complain is true, correct, and complete to the best of my knowledge.
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Choose
Yes
I understand that the complaint will be investigated and that, although the administration will protect the confidentiality of individuals providing information as best as possible, confidentiality of this complaint cannot be guaranteed.
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Choose
Yes
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