Bridger School District 3225F

Harassment Reporting Form for Students

School ______________________________________________ Date ____________________

Student’s name _________________________________________________________________

(If you feel uncomfortable leaving your name, you may submit an anonymous report, but please understand that an anonymous report will be much more difficult to investigate. We assure you that we’ll use our best efforts to keep your report confidential.)

Who was responsible for the harassment or incident(s)? _________________________________

______________________________________________________________________________

Describe the incident(s). __________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Date(s), time(s), and place(s) the incident(s) occurred. ___________________________________

_______________________________________________________________________________

______________________________________________________________________________

Were other individuals involved in the incident(s)? ‘ yes ‘ no

If so, name the individual(s) and explain their roles. _____________________________________

_______________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Did anyone witness the incident(s)? ‘ yes ‘ no

If so, name the witnesses. __________________________________________________________

________________________________________________________________________________

_______________________________________________________________________________

________________________________________________________________________________

Did you take any action in response to the incident? ‘ yes ‘ no

If yes, what action did you take? ____________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_________________________________________________________________________________

Were there any prior incidents? ‘ yes ‘ no

If so, describe any prior incidents. ___________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Signature of complainant ___________________________________________________________

Signatures of parents/legal guardians _________________________________________________