1. Today's Date:
2. School:
3. Name:
4. Phone Number:
5. Email Address:
6. I am a: (check the appropriate answer)
7. Alleged Targeted Student(s):
Student Name:
Student Age:
Days Absent:
8. Alleged Offender(s) (if known):
Offender Name:
School Name:
Age:
Student (Y/N):
Offender Days Absent:
9. Alleged Witness(es) (if known):
Witness Name:
Witness School:
Witness Age:
Witness Student (Y/N):
10. On what date(s) did the incident(s) happen?
11. Select which statement(s) best describes what happened (choose all that apply):
12. Where did the incident happen? (choose all that apply)
13. Describe the incident(s), including what the alleged offender(s) said or did:
14. Why do you think the bullying, cyberbullying, harassment, and/or intimidation occurred?
15. Did a physical injury result from this incident? (choose one of the following):
16. If there was a physical injury, do you think there will be permanent effects? (choose one of the following):
17. Was the student victim absent from school as a result of the incident?
18. If yes, how many days was the student victim absent from school as a result of the incident?
19. Did a psychological injury result from this incident? (choose one of the following)
20. Is there any additional information you would like to provide?
21. Electronic Signature:
22. Date:
Security Measure