North Colonie Central Schools
Shaker High School
Shaker Junior High School
Incident Report Form
Your Name: ____________________________________________________________________
Today’s Date: ____________
Who is bullying you? _____________________________________________________________
(If you don’t have a name, that’s okay)
How often has this person harassed or bullied you? _____________________________________
Describe what happened:
When did it happen? _____________________________________________________________
Where did it happen? _____________________________________________________________
How threatened do you feel by this person? (Circle one:)
| Irritated | Embarrassed | Worried | Frightened | Fearful |
Did anyone witness this incident? ____________________________________________________
Do you have evidence of this harassment? ____________________________________________
(texts, voicemails, Facebook/Twitter posts)
Did anyone assist you with this report? If yes, who? ______________________________________
**I certify that all statements on this form are accurate and true to the best of my knowledge.
____________________________________________________________________
signature
Adopted: June 18, 2012