2022-2023 Barker Road Incident Reporting Form

Incident Reporting Form

If your report involves an urgent or emergency event, please call police authorities at 911.

Concerns reported by students, staff and parents/guardians will be investigated and addressed by the District. Please use this form to report any of the following allegations:

discrimination by employees or students on school property or at a school function, including but not limited to such conduct based on a student’s actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender (defined to include gender identity or expression), or sex;
harassment and bullying incidents, including cyberbullying; and/or,
threats to students, staff or the school (such as thoughts of self-harm or suicide, violence, weapons, drugs/alcohol and theft). Call 911 first, then complete this form.

Please contact the school principal, counselor or Dignity Act Coordinator for additional assistance or information at any time.

The investigating administrator will respond to each allegation in the context of the law (including the Dignity for All Students Act) and/or the District’s Code of Conduct. All complaints will be treated in a confidential manner. You may choose to report this information anonymously. However, anonymous reports may limit the District’s ability to fully investigate and respond to the complaint.

Please note that false reporting of incidents will result in disciplinary consequences.

1.	Today’s date * (mm/dd/yyyy)

2.	Phone number

3.	Person reporting incident.

4.	Email address

5.	Person completing the form.
	Person completing the form. Student Parent/Guardian Staff Member Other

6.	If other, please describe.

7.	Do you wish to remain anonymous?
	Do you wish to remain anonymous? Yes No

8.	Name of target (if targeted at specific person/people or location).

9.	Name(s) of alleged offender(s).

10.	Did this incident already occur, or is this something that will/may happen in the future?
	Did this incident already occur, or is this something that will/may happen in the future? Already happened Will happen Unsure

11.	Please enter date of incident, if known.

12.	What is the incident you want to report? Please provide a general description of what happened including details before, during and after the event. If the event has not yet happened, please describe all that you know about the situation.

13.	Where did or will the incident happen?
	Where did or will the incident happen? On school property At a school sponsored activity On school bus Off school property Other

14.	Please provide additional details of where incident occurred or will occur.

15.

Which statement best describes what has happened or will happen?

Physical (including, but not limited to, kicking, punching, spitting, taking belongings)

Verbal (including, but not limited to, taunting, malicious teasing, name calling, verbal threats)

Psychological (including, but not limited to, non-verbal actions, spreading rumors, social exclusion)

Electronic communication

Threats of violence, injury to self, others or school

Other

16.	Describe what has happened or will happen.

17.	How did you become aware that the incident occurred or will occur? Who else is aware of this? How did they become aware?

18.	If you or anyone else became aware of the incident through text or social media, is a copy/screenshot/video available?
	If you or anyone else became aware of the incident through text or social media, is a copy/screenshot/video available? Yes No

19.	What steps, if any, have been made to resolve the issue? Please describe.

20.	If there is a student-victim involved, were they absent from school as a result of the incident that occurred or will occur?
	If there is a student-victim involved, were they absent from school as a result of the incident that occurred or will occur? Yes No

21.	If yes, how many days was the student-victim absent from school as a result of the incident?