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5312.4-E.3, Secondary Incident Report Form

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:)


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.


Adopted: June 18, 2012