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BASIC INFORMATION

Name of Student or Employee Who Was Harassed, Bullied or Intimidated: _________________________________

Check One---The above named person is: _____Employee _____Student

If Employee: Work Location: __________________ Phone: ________ Supervisor Name: _____________________

Mailing Address: _______________________________________________________________________________

If Student: School Name: ____________________ Grade: _________ Principal Name: _______________________

Mailing Address: _______________________________________________________________________________

Parent or Guardian Name: _____________________________________________ Phone: ___________________

Is this form being filled out by the student named above?                                   Yes                   No

If No, name/relationship of person filling out this form on behalf of the student named above: please print

 __________________________________________ ____________________________________________

                                    Name                                                                           Relationship                       

INFORMATION ABOUT THE INCIDENT:

Check any that describe the incident:         Harassment/ Sexual Harassment         Intimidation             Bullying

Name of individual(s) being reported:

Name(s):_____________________________________________________________________________________

When and where did the incident happen?

Date: ______________________ Time of Day; ____________  For about how long: ___hours ___minutes

Specific Location: ______________________________________________________________________________

What happened? Write a brief summary of the incident:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Who else might know something about this incident or what happened?

Name(s):______________________________________________________________________________________

Has this incident or something like it ever happened before?                      Yes                            No

If yes, when did it happen before? Date: ________________________ Location: _____________________________

Verification/Signature: This information is true and accurate.

Print Name: __________________________ Signature: ________________________ Date: __________