Harassment Reporting Form for Students
RISE Charter 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 guardian________________________________________________