Bullying Complaint Report Form
DISCLAIMER - Information from this form will be treated confidentially. We will only share this information with appropriate school personnel and law enforcement (if applicable).
Bullying is harmful behavior that is repeated, intentional, and involves an imbalance of power.
Victim Information
Please enter information about the victim below. Please be as specific as possible.
Victim's School
Victim's Name
Your answer
Person Reporting Incident (Optional)
Your answer
Phone Number of Person Reporting Incident (Optional)
(xxx)xxx-xxxx
Your answer
Email Address of Person Reporting Incident (Optional)
Your answer
Accused Information
Please enter information about the accused bully below. Please be as specific as possible.
Accused Bully Name OR Description
Your answer
Location of Incident
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Description of Incident
Describe what happened in as much detail as possible.
Your answer
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