District 96: Bullying Incident Report

District 96: Bullying Incident Report

Associated District 96 School*

This will route the information to the proper District 96 administrator.

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Please select which best describes your position.*

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Your Grade Level

If you are a District 96 student, please select your grade level.

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Date of the incident:*

Approximate Time of the Incident:*

Please also indicate AM or PM

Location of Incident*

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Previously Reported?*

Yes

Offender's Info*

This name field is required in order to investigate reported incidents.

Victim's Info*

This name field is required in order to investigate reported incidents.

Witnesses's Info

Incident Description*

Please, use concrete and clear wording:

Behaviors Involved Incident

(e.g., stealing, pushing, name calling, etc):

Incident Motivation (if known)

If so, please explain.

District 96 Staff Notified?

If so, list who was notified.

Physical Injuries (if any)

List only those that were a direct result of this incident.

Property Damage (if any)

List only those that were a direct result of this incident.

Contact Information (Optional)

Security Question: 4 + 3 =*

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Send me a copy of my responses