Harassment, Intimidation Or Bullying - Incident Reporting Form

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La Center School District No. 101
Harassment, Intimidation or Bullying - Incident Reporting Form
Reporting person (optional): _____________________________________________________________
Targeted student: ______________________________________________________________________
Your email address (optional): ____________________________________________________________
Your phone number (optional): ______________________Today’s date: _________________________
Name of school adult you’ve already contacted (if any): _______________________________________
Name(s) of aggressor(s) (if known):
_____________________________________________________________________________________
On what date(s) did the incident(s) happen (if known):
_____________________________________________________________________________________
Where did the incident happen?
Circle all that apply.
Classroom
Hallway
Restroom
Playground
Locker room
Lunchroom/Cafeteria
Sport field
Gym
Parking lot
School bus
Online/Internet Cell phone
During a school activity
Off school property
On the way to/from school
Other (Please describe.) _______________________________________________________
Please circle the action that best describes what the bully did. Please choose all that apply.
Damage to property
Gossip
Repeated behavior
Derogatory comments
Intimidation directed at me
Sexual stories/jokes/pictures
Disrespectful comments
Name calling
Sexual Orientation Slurs
Electronic / Cyberbullying
Offensive writing or graffiti
Slurs, rumors, jokes
Excluding me from activities
Physical harm or threats of harm
Spreading rumors
Hazing (Club, team, class, other)
Pranks
Threats (to me, friends, school)
Gender slurs
Put downs
Touching / grabbing
Gestures (Explain)
Racial slur(s)
Blocked movement
Other: (Please describe)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
3207F
Adopted 4/26/17

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