Form Ss-212 - Discrimination/harassment/bullying Incident Report Form
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1Discrimination/Harassment/Bullying Incident Report Form
This form is to be completed by the building administrator/designee for each incident of
discrimination, harassment or bullying on school grounds or during school-sponsored activities.
Date of Incident ____/_____/_____
Time _______
Location ______________
Reported by: ________________________________________________________________
Offender(s)/Student(s) Initiating Discrimination/Harassment/Bullying:
______________________________________________ Grade _____________
______________________________________________ Grade _____________
______________________________________________ Grade _____________
Victim(s)/Student(s) Affected:
______________________________________________ Grade _____________
______________________________________________ Grade _____________
______________________________________________ Grade _____________
Witness(es): _________________________________________________________________
Type: Racial ____ Sexual ____ Religious ____ Age_____ Disability_____
National Origin _____ Other _______________________
Behavior Displayed: Bullying ______
Being Bullied _____
___ Name Calling
___ Stalking
___ Inappropriate Gesturing
___ Staring/Leering
___ Threatening
___ Writing/Graffiti
___ Spitting
___ Stealing
___ Taunting/Teasing/Ridiculing
___ Hitting/Kicking
___ Shoving/
___Inappropriate Touching
___ Damaging Property
Pushing
___ Intimidation/Extortion
___ Demeaning Comments
___ Flashing a Weapon
___ Other _____________________________________________________________
Description of Incident: ______________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Physical Evidence: ___ Graffiti
___ Notes
___ E- mail
___ Other ____________
Offender(s) Consequence(s): ________________________________________________
Offender(s)’ Parent(s) Contacted:
Date______________________________
Victim(s) Support Provided: __________________________________________________
Victim(s)’ Parent(s) Contacted: Date _________________________________
Administrator(s) Signature _____________________________________ Date_________
SS-212
02/14/2011
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