Incident Report 2022-2023

If this is an emergency that needs immediate attention please call 911 or contact your health care provider immediately as this site is only monitored during school hours. Please be advised, if a report is made anonymously it will limit our investigation process and we will be unable to follow up with the person making the report. Students found responsible for deliberately making false reports may be subject to a full range of disciplinary consequences as publicized in student handbooks.

1.	Name of person completing the form:

2.	Name of person(s) targeted:*

3.	Name of the person or people identified as the alleged aggressor(s):

4.	Select the school building of the person being targeted:*
	--Please Select--Thomas Worthington High SchoolWorthington Kilbourne High SchoolLinworth AlternativeWorthington AcademyKilbourne Middle SchoolMcCord Middle SchoolPerry Middle SchoolPhoenix Middle SchoolWorthingway Middle SchoolBluffsview ElementaryBrookside ElementaryColonial Hills ElementaryEvening Street ElementaryGranby ElementaryLiberty ElementarySlate Hill ElementaryWilson Hill ElementaryWorthington Estates ElementaryWorthington Hills ElementarySutter Park PreschoolOther (Explain in Incident Description Box)

5.	What type of bullying are you reporting?
	Verbal    Physical    Cyber    Other, please specify

6.	Incident Date (When did this happen?)*
	mm/dd/yyyy

7.	Incident Place: Describe where the incident(s) have taken place*

8.	Incident Duration: (How long has this been going on?)*

9.	Incident Description: (Share details about what happened)*

10.	Were there any witnesses?

11.	What strategies have you used to try and deal with the situation?

12.	Feel free to add additional information that may help the administrator in completing the investigation into this incident:

	Click DONE to submit this information to the Worthington School District. Outcomes from this report will include further investigation and may result in discipline and/or supportive interventions. After you submit the report, your browser will be redirected back to the School Bullying information page.