Racist Incident Report Form

Racist Incident Record

School:______

Victim: ______Ethnic Origin:______

Year Group: ______

Perpetrator(s):______

Ethnic Origin(s):______

Year Group(s): ______

Date of incident: ______

Time of incident: ______

Location of incident: ______

Type of incident: Disrespect/non-co-operation

(tick as appropriate) Verbal harassment

Physical harassment

Damage to property

Racist graffiti

Incitement

Witness(es):______

Pupil/Adult: ______Year Group: ______

Incident reported by: Victim

(tick as appropriate) Observer

Other – specify

(e.g. parent, teacher, etc)

Action taken/to be taken: Discussion with pupil

(tick as appropriate) Information to class/form teacher

Referral to Head of Year/House

Letter to parents

Meeting with parents

Headteacher involvement

Fixed period exclusion

Permanent exclusion

Please make a brief note of the incident and actions taken, including details of effect on the victim, counselling undertaken etc. continue overleaf if necessary.

Signed:______Date:______

Please return to Safeguarding & Inclusion Team at BFC, Time Square, Market Street, Bracknell, RG12 1JD

e-mail: