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Harassment Incident Report Form
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School Building
*
Ferry/Voyager Elementary
Griffin Elementary
Lake Hills Elementary
Mary A. White Elementary
Peach Plains Elementary
Robinson Elementary
Rosy Mound Elementary
White Pines Intermediate School
Lakeshore Middle School
Central/Cyber High School
Grand Haven High School
District
Date of Incident
*
MM
/
DD
/
YYYY
Location of Incident
*
On Campus
Off Campus
On School Bus
Extra-curricular Event
Directly to or from School
Nature of the Allegation
*Check all that apply
*
Verbal conduct - slurs, threats
Written Conduct - notes, letters, social media
Non-verbal Conduct - gestures, intimidation
Physical Conduct - assault, battery
Other:
Required
Civil Rights Basis
*Check all that apply
*
Race
Sex Discrimination - Title IX
Sexual Harassment - Title IX
Ethnicity
Religion or Creed
Other:
Required
Date Reported to Police
If Applicable
MM
/
DD
/
YYYY
Summary of incident including any suspect names
*
Your answer
Victim Name
*
Your answer
Victim Status
*
Student
Employee
Other:
Witness(es)
*
Your answer
Name of person completing this form
*
Your answer
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