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Five Town CSD/CHRHS Bullying Report Form
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Name of complainant/reporter (by law, reports may be anonymous):
Your answer
Status of reporter:
Student
Parent
School Employee/Coach/Advisor
Other:
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Contact information for reporter (if reporter is student, contact information for parent/guardian):
Phone:
Your answer
Cell Phone:
Your answer
Email:
Your answer
Address:
Your answer
Name of alleged target(s):
Your answer
Name of alleged bully(ies):
Your answer
Relationship between alleged target/bully(ies):
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Time(s) and location(s) of alleged incident(s):
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Names of witnesses:
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Description of incident(s):
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I agree that the information on this form is accurate and true to the best of my knowledge and belief.
Entering your name serves as the signature for the complainant/reporter
Your answer
Note:
Reports of bullying may be made anonymously, but no disciplinary action shall be taken against a student solely on the basis of an anonymous report. Any student who has been determined to have made a false report of bullying will be subject to disciplinary consequences.
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