District Bullying Incident Report
If you have been the target of bullying or have witnessed the bullying of a Grain Valley School District student, complete the form below. Information submitted will be forwarded to the building principal where the incident occurred. Complaints against building principals will be submitted to the Superintendent. Complaints against the Superintendent will be submitted to the Board of Education. Reports of bullying will be investigated and disciplinary action will be taken as warranted.
Students have the right to complete this form anonymously. However, it will be easier for the School District to investigate this matter if as much information as possible is provided. Submission of a good faith complaint or report of bullying or harassment will not affect the complainant or reporter's future employment, grades, learning, or working environment. A complainant that falsely accuses someone will be subject to disciplinary action.
* Required
Today's date
*
MM
/
DD
/
YYYY
Your Name (optional)
Your answer
Contact Phone Number
Your answer
School Where Incident Occurred
*
Choose
Matthews Elementary
Sni A Bar Elementary
Prairie Branch Elementary
Stony Point Elementary
North Middle School
South Middle School
High School
Sni Valley Academy
Check the box of the person reporting the bullying
*
Student
Parent
Employee
Volunteer
Other:
Required
Date of bullying incident
*
MM
/
DD
/
YYYY
Time of bullying incident
*
Time
:
AM
PM
Name of person(s) subjected to bullying
*
Your answer
Person(s) alleged to have committed the bullying or harassment
*
Your answer
Summarize the incident(s) or occurrence(s) of bullying as accurately as possible.
*
Your answer
Names of Witnesses
Your answer
Have you reported this to anyone else?
*
Yes
No
Required
If you said yes above, please explain who you reported to
Your answer
Submit
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