Bullying Report Form
In accordance with state law, bullying is defined as intimidation, unwanted aggressive behavior, or harassment that is repetitive or is substantially likely to be repeated and causes a reasonable student to fear for his or her physical safety or property; that substantially interferes with the educational performance, opportunities or benefits of any student without exception; or that substantially disrupts the orderly operation of the school. Bullying includes, but is not limited to: physical actions, including violence, gestures, theft, or property damage; oral, written, or electronic communication, including name-calling, put-downs, extortion, or threats; or threats of reprisal or retaliation for reporting such acts.
School you attend:
Clinton High School
Clinton Technical School
Clinton Middle School
Clinton Intermediate School
Henry Elementary School
Clinton Early Childhood Center
Please describe what happened:
Where (school and location, i.e. hall, lunch room, playground, etc.) did the incident occur?
Were there any witnesses? If so, who?
How often has the bullying and/or harassment occurred?
How have you responded to the bullying and/or harassment?
Have you spoken with anyone about the incident? If so, who?
How can we contact you if we need more information?
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