SSISD Bullying Prevention and Intervention Incident Reporting Form

San Saba isd

Bullying is taken seriously by all administrators, teachers and staff within San Saba ISD.
Note: Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.

Name of Reporter/Person Filing the Report:

This line may be left blank if an anonymous report is being made.

Answer Required

Check whether you are the:*

Answer Required

Target of the behavior

Reporter (Not the target)

Check whether you are a:*

Answer Required

Student

Staff Member

Parent

Administrator

Other:

Your contact information/telephone number:

Optional if you want to be contacted.

Answer Required

If student, what campus are you on?

Answer Required

High School

Middle School

Elementary

If staff member, what campus are you on?

Answer Required

High School

Middle School

Elementary

Name of Target (of behavior):*

Answer Required

Name of Aggressor (Person who engaged in the behavior):*

Answer Required

Date(s) of Incident(s):*

Answer Required

Time When Incident(s) Occurred:*

Answer Required

Location of Incident(s) (Be as specific as possible):*

Answer Required

Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).*

Answer Required

Please fix the highlighted areas below before submitting.

SSISD Bullying Prevention and Intervention Incident Reporting Form