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Bullying Reporting

This Bullying, Harassment or Intimidation Reporting Form should be used to report alleged incidents of bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school, or through electronic communication on or off school property.

School staff will address incidents that occur at school or have a connection or nexus back to the school setting that create a risk of harm to other students while they are at school or interfere with the educational environment.

If you are a student, the parent/guardian or caregiver of a student, a close adult relative of a student, a school staff member, or a bystander and wish to report an incident of alleged bullying, cyberbullying, harassment, or intimidation, please complete this form.

You may contact the school for additional information or assistance at any time.
 


 

Required

Must contain a date in M/D/YYYY format
 

Person Reporting Incident
Name of Person Reporting the Incidentrequired
First Name
Last Name

 

 


Alleged Targeted Student(s)
Please include name, age, and days absent as a result of the incident (if known)

 

 


Alleged Offender(s)
Please include name, age, school, and days absent as a result of the incident (if known)

 

 


Alleged Witness(es) 
Please include name, school, age, and if they are a student or not (if known)

 

 


When did the incident(s) occur...
Month / Date / Year

 

 


Describe what happened...
Select the statement(s) that best describes what happened (choose all that apply):required

 

 


When did the incident happen...
Where did the incident happen? (Select the statement(s); choose all that apply)requiredPlease select up to 8 choices
Please select up to 8 choices

*Will be collected unless specifically excluded by local board policy

 

 


Provide more details...
Did a physical injury result from this incident? Select one of the following:
If there was a physical injury, do you think there will be permanent effects?
Was the student victim absent from school as a result of the incident?
Did a psychological injury result from this incident? Select one of the following:

 

 


Any other additional information...

 

 


Signature required...
Must contain a date in M/D/YYYY format