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PERSON REPORTING INCIDENT:
Last Name: First Name:
Telephone:
A confirmation email will be sent to your email address:
*Select the appropriate box:

STUDENT VICTIM:
* School:
Last Name: First Name:
Middle Name: Age:

*On what date did the incident happen?  (mm/dd/yyyy)
Alleged Witness(es) (if known):
Last Name First Name Age School
1st
2nd
3rd

Alleged Offenders: (Please enter 'Unknown' in Last Name field if you don't know the offender's name)
Last Name First Name Age Sch # School *Is he/she a Student?
1st
2nd
3rd
4th
5th

*Where did the incident happen (choose all that apply)?






*Check the boxes that best describe what happened (choose all that apply):
















*What did the alleged offender(s) say or do?


*Why did the harassment or initimidation (bullying) occur?


*Did a physical injury result from this incident? Please select one of the following:  
*If there was a physical injury, do you think there will be permanent effects?       
*Was the student victim absent from school as a result of the incident?                    *If yes, how many days was the student victim absent from school as a result of the incident?     
*Did a psychological injury result from this incident? Please select one of the following:  
Is there any additional information you would like to provide?


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