Incident Complaint Harassment / Bullying Form (RHS)

Name of Person Reporting Incident(s)

Check whether you are the:

Victim\target of behavior (or his/her parent/guardian)

Reporter (not victim or target)

Check whether you are a:

Student (Specify):

Staff Member (Specify):

Parent/Guardian (Specify):

Other (Specify):

Provide Tel. No.; E-mail address:

If student, state school name:

If staff member, state school name or work site:

Name of Victim/target of behavior:

Student Name:

Employee:

Other Name:

Name of Subject (person who engaged in behavior):

Student Name:

Employee Name:

Other:

Location:

Date and time of incident:

Class:

Hall:

Cafeteria:

Other area inside school:

School grounds:

Bus:

Other:

Nature of incident (check all that apply)

Physical:

Verbal:

Gesture:

Electronic:

Written:

Personal Property:

School Property:

Other:

Witnesses (who saw incident or has information about why incident occurred)

1. Name: (Specify student, employee, or other):

2. Name: (Specify student, employee, or other):

3. Name: (Specify student, employee, or other):

Describe the details of the incident, in the order it happened, and specifying where it occurred. Identify what each person involved did and said, stating actual words used.

Give any background information that may help explain how or why incident occurred.

Leave this field blank