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: _________________