Ralston Incident Report

Incident Report

You may use this form to report a conflict, bullying, or other inappropriate behavior. You may fill this out for yourself (if you are the target) or for someone else if you are being an Upstander.

Your Name*

First Name

Last Name

What Grade are you in?*

6th Grade 7th Grade 8th Grade

What is the name of the student (s) being targeted?*

First Name

Last Name

What is the grade of the student who is being targeted? *

6th Grade 7th Grade 8th Grade

What is the name(s) of the student(s) who was bullying or using inappropriate behavior*

Please provide First and Last Names

What is the grade of the student who was bullying or using inappropriate behavior?

6th Grade 7th Grade 8th Grade

If this occurred during class time, which period?

If this occurred during class time, which teacher's class was it?

What was the date that this happened?*

What time of day did this happen?*

Before School After School During Class Snack Time Lunch During passing period On the weekend

How often is the behavior happening?*

1 2 3

Range from 1 "Has only happened once" to 3 "Very Often (almost daily)"

How bad is the behavior?*

1 2 3

Range from 1 "It is annoying" to 3 "I do not want to come to school until it stops"

How safe do you feel when you are at school?*

1 2 3 4 5

Range from 1 "Very unsafe" to 5 "Very Safe"

Describe how the incident occurred (Optional)

You may choose to tell what happened in more detail