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Harassment/Bullying Form
Use this form to report harassment, intimidation or bullying. (If you feel uncomfortable leaving your name, you may submit an anonymous report, but understand that it will be much more difficult to investigate. We assure you that we'll use our best efforts to keep your report confidential.)
First Name
Your answer
Grade *
Your answer
Harasser *
Your answer
Last Name
Your answer
Nature of Harassment *
Check All That Apply
Required
Description *
What They Said, Wrote, Etc.
Your answer
Date(s), time(s), period(s), place(s) the harassment took place. *
As best as you can remember
Your answer
Were other individuals involved in the incident(s)? List those individuals and their roles.
Instigators or others "egging on" the incident
Your answer
List Any Witnesses
Preferably Credible Sources
Your answer
What actions have you taken in response to the harassment? *
Comments, E-mails, Texts, Postings etc.
Your answer
History of Conflict *
Where, when (ie. a house party over the weekend, a posting on Facebook, or a text message to you or a friend)
Your answer
PLEASE PRINT A COPY FOR YOUR RECORDS!
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