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Sacred Heart School Behavioral Incident Report

According to Washington State law, bullying is any negative action that is intentional, repeated, negative, shows a lack of empathy, and involves a power imbalance. This definition also applies to interaction.

About the incident

Date of incidentrequired (mm/dd/yyyy)

Have you reported this situtation to the school before?

Yes No

If yes, to whom?

Is this repetitive behavior?

Yes No

If yes, at what other times has this happened?

Where did the incident happen?

If it was over digital media, can you indicate the channel (text, Facebook, Twitter, etc.)?

Please describe the incident. What happened? (e.g., name calling, intimidation, physical attack, retaliation, exclusion, threats, etc.)?

Is there anything else that may help us to understand what happened in this incident(s)?

About the people involved in the incident:

Name of person experiencing negative behaviors:

If unknown, please describe including gender, height, hair color, etc.

Name of person accused of bullying:

If unknown, please describe including gender, height, hair color, etc.

Were there any witnesses? Please, give us the name(s):

If unknown, please describe including gender, height, hair color, etc.

Additional information:

What makes you think that this is bullying and not some other sort of negative, rude, or unacceptable behavior?

Information about you:

Name:required

Email Fieldrequired

Today's Date:required (mm/dd/yyyy)