Waynoka Public Schools

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Bullying/Harassment Incident Form

Please complete this form to the best of your knowledge so we can assist you.
This information will be kept confidential with your campus administrator and/or superintendent.

Procedures located in Waynoka Board Policy FNCD will be used by any person for the filing, processing, and resolution of a reported incident of harassment, intimidation, bullying, or threatening behavior. The procedures are followed by the administration of the school district in an effort to determine the severity of the incident and the potential to result in future violence. “Bullying” means any pattern of harassment, intimidation, threatening behavior, physical acts, verbal or directed toward a student or group of students that results in or is reasonably perceived as being done with the intent to cause negative educational or physical results for the targeted individual or group and is communicated in such a way as to disrupt or interfere with the school’s educational mission or the education of any student.

Please Fill Out The Bullying/Harassment Incident Form Below

Date of Incident:

Date of Report:

Who was the person(s) engaged in bullying?

Grade of person(s) who engaged in bullying?

Who was being bullied?

Grade of person who was being bullied?

What type of bullying?

Reaquired field: Physical

Reaquired field: Emotional/Social

Reaquired field: Damage to Property

Reaquired field: Online

Witnesses Present:

Other location details: (Please explain the specific location details such as which hallway, where on the Internet, what restroom, etc)

Describe what happened with as many details as possible.

Is there any physical evidence that can be given to the administration?

Graffiti

Notes

E-mail/Text Messages

Websites

Video/audio tape

Other

Person reporting the incident:(OPTIONAL). Please use your full name.

Please provide contact number if different than school directory information.

Thank you for reporting this incident. We appreciate your concern. When you click "Submit Form" this will be sent to the campus administrator.

Email a copy to

optional

Required Fields