WPS Challenging Behavior Reporting Form

Instructions

This form is for students, parents or guardians of students enrolled in the school, and school employees to report any alleged challenging behavioral incidents. Challenging behavior is behavior that negatively impacts school climate or interferes, or is at risk with interfering, with the learning or safety of a student or the safety of a school employee. This form should also be used to report alleged bullying incidents, meaning: unwanted and aggressive behavior among children in grades kindergarten to twelve, inclusive, that involves a real or perceived power imbalance.

All completed reports require a response from the school climate specialist, and every student, parent or guardian, and school employee who completed this form will receive a copy of the “Response Process(es) Notification Form” describing the action steps taken, within three (3) school business days after an assessment has been completed.

A confirmation of receipt will be provided to the individual who completed this form within three (3) school business days, and the behavioral assessment will be finalized within a reasonable amount of time.

If this is an emergency, and you feel that you or someone else is in imminent danger, please call 911, or your municipal police department.

First and last name of person submitting this report:

Answer required for "First and last name of person submitting this report:"

I am a:*

Answer required for "I am a:"

Student

Parent/Guardian

School Employee

Email:

Answer required for "Email:"

Phone:

Number Required

School students involved attend:*

Answer required for "School students involved attend:"

If this was this previously reported to any school personnel prior to this report please identify whom, when, and what was reported.

Answer required for "If this was this previously reported to any school personnel prior to this report please identify whom, when, and what was reported. "

Where did the incident occur? Check any boxes that apply.*

Answer required for "Where did the incident occur? Check any boxes that apply."

On school property

At a school-sponsored activity

Electronic communication, internet, and/or social media

On a school bus

Other:

Date of incident*

Answer required for "Date of incident"

Please describe what happened:*

Answer required for "Please describe what happened:"

of the following statement(s) check any that may describe or include what happened:*

Answer required for "of the following statement(s) check any that may describe or include what happened:"

Teasing, name-calling, intimidating, or threatening, in person or through electronic communication

Spreading rumors or gossip

Hitting, kicking, shoving, spitting, hair pulling, or throwinng something or other acts of physical aggression

Making intimidating, and/or threatening gestures or remarks

Getting another person to do any of the behaviors listed above

Unwanted contact of a sexual nature (verbal, non-verbal, physical)

Other:

Do you believe that the reported instance(s) of challenging behavior was in reference to a student’s perceived or actual age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical disability, mental disability, race, religious creed, sex, gender identity or expression, sexual orientation, and status as a veteran? If so, why?*

Answer required for "Do you believe that the reported instance(s) of challenging behavior was in reference to a student’s perceived or actual age, ancestry, color, learning disability, marital status, intellectual disability, national origin, physical disability, mental disability, race, religious creed, sex, gender identity or expression, sexual orientation, and status as a veteran? If so, why?"

If known, provide the name(s) of any witness(es) of the alleged incident:

Answer required for "If known, provide the name(s) of any witness(es) of the alleged incident:"

*Before submitting - please view our privacy policy which explains how we use the information collected in this form, for challanging behavior reporting related procedures.

Please fix the highlighted areas below before submitting.

WPS Challenging Behavior Reporting Form