INCIDENT AND ALLEGED HARASSMENT REPORT FORM

Confidential – For safeguarding and internal reporting purposes

1. Reporting Person

Name: __________________________________________________

Position/Role: ___________________________________________

Date of report: ___________________ Time: ______________

2. Incident Classification

☐ Minor incident

☐ Major incident

3. Incident Details

Date of incident: ___________________ Time: ______________

Location: __________________________________________________

Student(s) or staff member(s) affected: __________________________

Course/Class: ______________________________________________

4. Student(s) Allegedly Involved in Initiating the Incident

Student 1: _________________________________ Grade/Class: __________

Student 2: _________________________________ Grade/Class: __________

Student 3: _________________________________ Grade/Class: __________

Student 4: _________________________________ Grade/Class: __________

5. Witnesses

Witness 1: __________________________________________________

Witness 2: __________________________________________________

Additional witnesses or contact details:

6. Nature of the Alleged Harassment

Tick all that apply.

☐ Racial or ethnic harassment

☐ Sexual harassment

☐ Religious harassment

☐ Other: __________________________________________________

Frequency of incident:

☐ Repeated incidents

☐ One-time incident

☐ Unknown at the time of reporting

7. Behaviour Reported

Tick all that apply.

Verbal, written or non-verbal behaviour

☐ Inappropriate gestures or non-verbal expressions

☐ Verbal argument or confrontation

☐ Written or verbal threats

☐ Inappropriate or offensive written notes or messages

☐ Spreading rumours, verbally or in writing

☐ Humiliating, embarrassing or ridiculing another student

☐ Other: __________________________________________________

Physical behaviour

☐ Physical confrontation or fight

☐ Physical contact or assault

☐ Physical injury reported or observed

☐ Other: __________________________________________________

8. Description of the Incident

Record the facts as reported or observed, including the sequence of events and the words or actions involved where relevant. Distinguish between direct observations and information reported by others.

9. Immediate Action Taken

☐ Students separated, where necessary for safety

☐ First aid or medical assistance provided or requested

☐ Designated safeguarding lead or responsible staff member informed

☐ Parent/guardian contacted, where appropriate and in accordance with safeguarding procedures

☐ School management informed

☐ External authorities contacted, where required

☐ Other action: _______________________________________________

Details of action taken:

10. Further Action and Follow-Up

Person responsible for follow-up: _________________________________

Action required: ______________________________________________

Follow-up date: ______________________________________________

Date resolved or reviewed: _____________________________________

11. Declaration

I confirm that this report records the information available to me at the time of reporting, to the best of my knowledge.

Reporting person's signature: __________________________________

Date: ___________________

Received by: _________________________________________________

Position: __________________________ Date: _________________

Confidentiality notice: This report contains potentially sensitive personal information, including information concerning minors. It must be stored securely and shared only with authorised persons who need the information for safeguarding, investigation or other legitimate purposes. Allegations must be recorded objectively and must not be treated as established facts until appropriately assessed.