Incident Report - Yoakum Primary School

1.	Date of Report*
	mm/dd/yyyy

2.	Your name (optional)

3.	Your relationship to the alleged victim or offender (optional)

4.	Your contact number (optional)

	Alleged Victim/Bully Information

5.	Persons Involved
	Name   Grade Alleged Victim     Alleged Bully #1     Alleged Bully #2     Alleged Bully #3

6.	List any witnesses to the incident.
	Witness 1   Witness 2   Witness 3   Witness 4

	Information about the Incident

7.	Incident Date*
	mm/dd/yyyy

8.	Time of Incident*

9.	Location of Incident. Please be specific.*

10.	Did the alleged incident take place on school property?*
	Did the alleged incident take place on school property?* YesNo

11.	Did the alleged incident take place during the school day?*
	Did the alleged incident take place during the school day?* YesNo

12.	Did the alleged incident occur at a school-sponsored activity?*
	Did the alleged incident occur at a school-sponsored activity?* YesNo

13.	Please describe the alleged incident.*

14.	Is this the first incident?*
	Is this the first incident?* YesNo

	Click Done to submit your report. By clicking Done, you affirm that the information is true and correct.