Bullying and any type of Harassment are serious and will not be tolerated. If you are a student, the parent/guardian of a student, a volunteer or visitor, and wish to report an incident of alleged harassment and/or bullying inside or outside the campus, complete this form and submit it.School employees are required to report alleged violations. Feel free to contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting signature and name. Every reported act of bullying or harassment will be investigated, and parents and the responsible authority will be informed.
First Name of student victim Last Name of student victim School of Victim
       

 On what date did the incident happen? Calendar  

 Name(s) of alleged offender(s) (If Known)
  Offender First Name Offender Last Name Grade  School Is he/she a student?
1
2
3
  Location of the incident:   Other:
  Which statement(s) best decribes what happened?
 Teasing  Social  Exclusion  Threat  Intimidation Stalking  Physical violence Theft Public humiliation  Cyber bullying
 What did the alleged offender(s) say or do?
 

 
  Contact information (optional)
Name/Title of person reporting incident         Phone:    
Student   Parent/guardian   Close adult relative

 

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