EVI EduForm

Incident Reporting Form

(For District/School Files Only)

To be completed by person reporting the incident (or the person receiving the complaint and/or investigating the incident

School District: ____________________________________

School: __________________________________

Dignity Act Coordinator: ___________________________________

Position: ___________________________

Today's Date: _______________

Name of person reporting incident: __________________________

Role of person reporitng incident (Check one)

_____________________

Phone: ____________________

Email: _____________________________

Student Target

Student (witness)

Parent/Guardian

Staff Member

Other:

Name of target: (student being bullied, harassed, or discriminated against)

___________________________________________________

Name(s) of alleged offender(s): ______________________________________________________________________

Date(s) and time(s) of incident: ____________________________________________________________________

What was your involvement in the incident?

I was directly involved in the incident

I observed the incident

I heard about the incident

Where did the incident happen? (Check all that apply)

________________________________

On School Property

Cafeteria

On a school bus

Classroom

Gym

Off school property

Hallway

Locker Room

Electronic Communication

Bathroom

At a school function

Other (describe):

Type of Incident (Check all that apply)

________________________________________________________________________

Physical contact (kicking, punching,spitting, tripping, pushing, taking belongings)

Verbal threats (gossip, name-calling, put-downs, teasing, being mean, taunting, making threats)

Psychological (non-verbal actions, (non-verbal actions, spreading rumors, social exclusion, intimidation)

Abuse (actions or statements that put an individual in fear of bodily harm)

Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures (sexting))

Other (describe):

Who was involved in the incident?

Describe the specific nature of the incident. What happened? (Be as specific as possible).

What did the alleged offender say or do? Include any copies of text messages, emails, etc. if possible.

Upload one file of all documents here:

Student

Employee

Both student and employee

If there were any adults in the area when this happened, what did they do?

Types of bias involved (if known): (Check all that apply)

____________________________

Race

Religion

Sex

Color

Religious practice

Weight/Size

Disability

National Origin

Sexual orientation

Ethnic Group

Gender

Other (describe):

Names of others who may have witnessed the incident?

______________________________________________________________________________________________

Was the student absent from school as a result of the incident?

Number of days student was absent: __________

No

Yes

Does the situation continue to occur?

Yes

No

What do you think should be done about the situation?

You can contact the school administrator, Dignity Act Coordinator, counselor, or other staff member (whoever you are most comfortable with) for information at any time.