South Washington County Schools Bullying Report Form
General Statement of Policy Prohibiting Bullying

An act of bullying, by either an individual student or a group of students, is expressly prohibited on school premises, on school district property (leased or owned), at school functions or activities, or on school transportation. This policy applies not only to students who directly engage in an act of bullying but also to students who, by their indirect behavior, condone or support another student’s act of bullying. This policy also applies to any student whose conduct at any time or in any place constitutes bullying or other prohibited conduct that interferes with or obstructs the mission or operations of the school district or the safety or welfare of the student or other students, or materially and substantially interferes with a student’s educational opportunities or performance or ability to participate in school functions or activities or receive school benefits, services, or privileges. This policy also applies to an act of cyber-bullying regardless of whether such act is committed on or off school district property and/or with or without the use of school district resources.
Complainant Information
Alleged Target Name (FIRST LAST)
Your answer
Home Phone
Your answer
Home Address
Your answer
Work Phone
Your answer
Cell Phone Number
Your answer
Best Time to Contact
Best Number to Contact
Identifying Information
Date(s):
Your answer
Location
Your answer
Alleged Bully or Bullies Names(s)
Your answer
Name(s) of Bystanders
Your answer
Description of Incident
Describe the incident(s) in detail. Please include any verbal statements (i.e. threats, requests, demands, name calling) or whether any physical force or contact was involved.
Your answer
By electronically signing my name below, I certify that this complaint is filed based on my belief that the above named individuals have bullied me or another person. I hearby certify that the information I have provided in this complaint is true and complete to the best of my knowledge. *
(Type your name below)
Your answer
Date of Complaint *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of South Washington County Schools. Report Abuse