Bullying/harassment Incident Report Form - Oklahoma State Department Of Education Page 2
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2 Electronic communication
Identify the component used:
Cell phone
Audio or visual image
Instant message/email
Gaming
Social Networking
Blog
Other: ____________________________
Damage of student’s property
Property damage
Stolen or missing property
Other: ____________________________
Reasonable fear of harm to person or property
Fear of harm to person
Fear of harm to property
Other: ____________________________
Disrupt or interfere with school’s educational
Changes in attendance: absences, tardies
mission or the education of student.
Missing classes/parts of school day
Changes in grades
Changes in participation of school
activities
Avoidance of elements: lunch, bus, recess
Other: ____________________________
Additional details of the incident:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Physical evidence: Graffiti Notes E-mail Web sites_______________________
Video/audiotape
Other____________________________________
Was the affected student absent from school as a result of this incident?
Yes No
What was the reason? ____________________________________________________________
How many days? _______________________________________________________________
Has a complaint relevant to this incident been filed before?
Where:____________________ With Whom: ______________ When: ____________________
I agree that all of the information is accurate and true to the best of my
knowledge.
Signature (optional): ______________________________________ Date: _________________
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