Editing previous response:

Please fix the highlighted areas below before submitting.

Employee Incident Reporting Form

This form is for employees to report incidents including, but not limited to, bullying, discrimination, sexual harassment, dating violence, and threats.

Victoria ISD has a strong policy regarding employee welfare and crisis intervention. If you have experienced a harmful, threatening, or violent situation while at work please complete the form below or talk with your immediate supervisor.

Should you need counseling resources because you were a victim or witness to a threat, please contact the SupportLinc Employee Assistance Program at 1-800-475-3EAP (3327) or www.supportlinc.com, username: victoriaisd

Today's date:*

Answer Required

Name of person completing this form (optional):

Answer Required

Relationship to alleged victim/offender (optional):

Answer Required

Contact number (optional):

Number Required

Incident Information:

Alleged Perpetrator's Name:*

Answer Required

Campus/Department:*

Answer Required

Intended Target/Victim Name #1:*

Answer Required

Intended target/victim name #2:

Answer Required

Intended target/victim name #3:

Answer Required

Date of Incident:*

Answer Required

Time of Incident:*

Answer Required

Where did the incident occur?*

Answer Required

Incident Description:*

Answer Required

Name(s) of witness(es) to incident:

Witness name #1*

Answer Required

Witness name #2

Answer Required

Witness name #3

Answer Required

Witness name #4

Answer Required

Has anyone helped you with this complaint?*

Answer Required

Yes

If yes, who was it and what was done?

Answer Required

Is this the first incident?*

Answer Required

Yes

If no, how many times has this happened before?

Answer Required

Please provide information about previous incidents including the name(s) of school staff to whom these previous reports were made.

Answer Required

Agreement

I certify that all statements made on this form are true, correct, and complete. Any intentional misstatement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary to pursue the investigation.

Type your full name here for a digital signature (optional)

Answer Required

Confirmation Email

Enter your email address here if you'd like to receive a confirmation upon submitting the form.

Email Required