"Bullying/Harassment Incident Report Form" - Oklahoma

Bullying/Harassment Incident Report Form is a legal document that was released by the Oklahoma State Department of Education - a government authority operating within Oklahoma.

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Download "Bullying/Harassment Incident Report Form" - Oklahoma

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Bullying/Harassment Incident Report Form
Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “…adopt a policy
for the control and discipline of all children attending public school in that district, and for the
investigation of reported incidents of harassment, intimidation, bullying, or threatening
behavior.” This report form will assist districts in collecting reported incidents of such behavior.
Reporting Person Information (optional)
Name: _______________________________________ Relationship: _____________________
Telephone: ____________________ E-Mail: _________________________________________
Incident Details
School Site: ___________________________________________________________________
Date: ____________________ Time: _________________ Room/Location: ________________
Student Affected:
____________________________________
Grade: _____
Class: ________________
Student(s) Initiating Bullying/Harassment:
____________________________________
Grade: _____
Class: ________________
____________________________________
Grade: _____
Class: ________________
Witness: ______________________________________________________________________
Witness: ______________________________________________________________________
Type of Alleged Harassment
 Racial
 Sexual
 Religious  Other__________________________________
If you checked any item above and you are not getting help from the district, contact the US
Department of Education’s Office of Civil Rights to file a complaint.
Yes, this is a repeated offence.
 No, this is a one-time incident.
Check all spaces below that apply. Inappropriate behaviors include:
 Gesture, written, or verbal expression
 Verbal fight
 Written or verbal threat
 Written note
 Written or verbal rumors
 Seclusion
 Embarrassing the student
 Other: ____________________________
 Physical Act
 Physical fight
 Physical injuries
 Other: ____________________________
Bullying/Harassment Incident Report Form
Oklahoma School Security Act (70 O.S. § 24-100.3) requires each district to “…adopt a policy
for the control and discipline of all children attending public school in that district, and for the
investigation of reported incidents of harassment, intimidation, bullying, or threatening
behavior.” This report form will assist districts in collecting reported incidents of such behavior.
Reporting Person Information (optional)
Name: _______________________________________ Relationship: _____________________
Telephone: ____________________ E-Mail: _________________________________________
Incident Details
School Site: ___________________________________________________________________
Date: ____________________ Time: _________________ Room/Location: ________________
Student Affected:
____________________________________
Grade: _____
Class: ________________
Student(s) Initiating Bullying/Harassment:
____________________________________
Grade: _____
Class: ________________
____________________________________
Grade: _____
Class: ________________
Witness: ______________________________________________________________________
Witness: ______________________________________________________________________
Type of Alleged Harassment
 Racial
 Sexual
 Religious  Other__________________________________
If you checked any item above and you are not getting help from the district, contact the US
Department of Education’s Office of Civil Rights to file a complaint.
Yes, this is a repeated offence.
 No, this is a one-time incident.
Check all spaces below that apply. Inappropriate behaviors include:
 Gesture, written, or verbal expression
 Verbal fight
 Written or verbal threat
 Written note
 Written or verbal rumors
 Seclusion
 Embarrassing the student
 Other: ____________________________
 Physical Act
 Physical fight
 Physical injuries
 Other: ____________________________
 Electronic communication
Identify the component used:
 Cell phone
 Audio or visual image
 Instant message/email
 Gaming
 Social Networking
 Blog
 Other: ____________________________
 Damage of student’s property
 Property damage
 Stolen or missing property
 Other: ____________________________
 Reasonable fear of harm to person or property
 Fear of harm to person
 Fear of harm to property
 Other: ____________________________
 Disrupt or interfere with school’s educational
 Changes in attendance: absences, tardies
mission or the education of student.
 Missing classes/parts of school day
 Changes in grades
 Changes in participation of school
activities
 Avoidance of elements: lunch, bus, recess
 Other: ____________________________
Additional details of the incident:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Physical evidence:  Graffiti  Notes  E-mail  Web sites_______________________
 Video/audiotape
 Other____________________________________
Was the affected student absent from school as a result of this incident?
 Yes  No
What was the reason? ____________________________________________________________
How many days? _______________________________________________________________
Has a complaint relevant to this incident been filed before?
Where:____________________ With Whom: ______________ When: ____________________
I agree that all of the information is accurate and true to the best of my
knowledge.
Signature (optional): ______________________________________ Date: _________________
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