HIBIRS School of the Arts

Harassment and Bullying Incident Reporting Form

Harassment, Intimidation and Bullying Incident Reporting Form

In the Rochester City School District, we are focused on providing a positive and respectful learning environment for students and staff. The District’s primary emphasis is on prevention however if an incident of harassment, intimidation, or bullying occurs, it will be taken very seriously and responded to in a way to reduce the likelihood of it happening again.

The purpose of this online tool is to provide an additional way for students, staff, families, and community members to alert school personnel and report incidents of harassment, intimidation, and bullying that may involve bias (real or perceived). It is recommended that you go directly to school personnel when possible for a more immediate response. If you are in crisis and would like to talk about your experience and receive support from a trained crisis counselor, please contact 2-1-1/LIFE LINE by dialing 2-1-1 or 275-5151 for 24 hour assistance.

1.	Today's Date:
	mm/dd/yyyy

2.	Person Reporting Incident: You may choose to report this information anonymously. All complaints will be treated in a confidential manner. Anonymous reports may limit the district’s ability to respond to the complaint.

3.	Phone Number:

4.	Email:

5.	Person completing this form is a:*
	Person completing this form is a:* Student Student (witness/bystander of incident) Parent/Guardian Staff Member Community Member

6.	Name of Target:*

7.	Name(s) of alleged offender(s):

8.	Date(s) of Incident(s):

Where did the incident happen?
Choose all that apply below.
Select at least 0 and no more than 0.

On school property

Off school property

At a school sponsored activity

On a school bus

Online

Other, please specify

10.

Place a check next to the statement(s) that best describes what happened (choose all that apply)
Select at least 0 and no more than 0.

Physical (including, but not limited to, kicking, punching, spitting, taking belongings)

Verbal (including, but not limited to, taunting, malicious teasing, name calling, making threats)

Psychological (including,but not limited to, non-verbal actions, spreading rumors, social exclusion)

Electronic communications

Other, please specify

11.	Background: Please describe what happened before, during and after the incident

12.	Who else saw the incident occur?

13.	What steps, if any, have been tried to resolve the issue?

14.	To your knowledge, was the student victim absent from school as a result of the incident?
	To your knowledge, was the student victim absent from school as a result of the incident? YesNo

15.	If yes, how many days was the student victim absent from school as a result of the incident?