__________School District                                                                                                                     

3225F

             

Harassment Reporting Form for Students

 

School ______________________________________________       Date ___________________

 

Student’s name _________________________________________________________________

(If you feel uncomfortable leaving your name, you may submit an anonymous report, but please understand that an anonymous report will be much more difficult to investigate.  We assure you that we’ll use our best efforts to keep your report confidential.)

 

Who was responsible for the harassment or incident(s)? ______________________________

______________________________________________________________________________

 

Describe the incident(s). ______________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Date(s), time(s), and place(s) the incident(s) occurred. _______________________________

______________________________________________________________________________

______________________________________________________________________________

 

Were other individuals involved in the incident(s)?  __ yes     __ no

If so, name the individual(s) and explain their roles. ____________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Did anyone witness the incident(s)?  __ yes     __ no

If so, name the witnesses. ________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Did you take any action in response to the incident?  __ yes     __ no

If yes, what action did you take? ___________________________________________________

______________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________

 

Were there any prior incidents?  __ yes     __ no

If so, describe any prior incidents. __________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Signature of complainant _________________________________________________________

 

Signatures of parents/legal guardians _______________________________________________