Reporting Person: __________________________________________ ⃝ Minor incident________Major incident Incident Details: Date: _________________ Time: _________________ Location: ______________________ Student/Teacher Affected: ____________________________Course: __________________ Student(s) Initiating Incident: Name: ____________________________________Grade: _______________________

Name:_____________________ ___________________Grade: _______________________

Name: ________________________________________ Grade: _______________________

Name: ________________________________________ Grade: _______________________

Witness: ___________________________________________________________________

Witness: ___________________________________________________________________

Type of Alleged Harassment: ⃝ Racial ⃝ Sexual ⃝ Religious ⃝ Other: ________________ ⃝

Yes, this is a repeated offense. ⃝ No, this is a one-time incident.

Check all the spaces below that apply. Inappropriate behaviours include: ⃝Gesture, written, or verbal expression ⃝ Verbal fight ⃝ Written or verbal threat ⃝ Written note ⃝ Written or verbal rumours ⃝ Embarrassing the student ⃝ Other: __________________ ⃝

Physical Act ⃝ Physical fight ⃝ Physical injuries ⃝ Other: _________________