Bullying/harassment Incident Report Form - Oklahoma State Department Of Education
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2Bullying/Harassment Incident Report Form
Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “…adopt a policy
for the control and discipline of all children attending public school in that district, and for the
investigation of reported incidents of harassment, intimidation, bullying, or threatening
behavior.” This report form will assist districts in collecting reported incidents of such behavior.
Reporting Person Information (optional)
Name: _______________________________________ Relationship: _____________________
Telephone: ____________________ E-Mail: _________________________________________
Incident Details
School Site: ___________________________________________________________________
Date: ____________________ Time: _________________ Room/Location: ________________
Student Affected:
____________________________________
Grade: _____
Class: ________________
Student(s) Initiating Bullying/Harassment:
____________________________________
Grade: _____
Class: ________________
____________________________________
Grade: _____
Class: ________________
Witness: ______________________________________________________________________
Witness: ______________________________________________________________________
Type of Alleged Harassment
Racial
Sexual
Religious Other__________________________________
If you checked any item above and you are not getting help from the district, contact the US
Department of Education’s Office of Civil Rights to file a complaint.
Yes, this is a repeated offence.
No, this is a one-time incident.
Check all spaces below that apply. Inappropriate behaviors include:
Gesture, written, or verbal expression
Verbal fight
Written or verbal threat
Written note
Written or verbal rumors
Seclusion
Embarrassing the student
Other: ____________________________
Physical Act
Physical fight
Physical injuries
Other: ____________________________
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