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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
Grade *
Harasser *
Last Name
Nature of Harassment *
Check All That Apply
Required
Description *
What They Said, Wrote, Etc.
Date(s), time(s), period(s), place(s) the harassment took place. *
As best as you can remember
Were other individuals involved in the incident(s)? List those individuals and their roles.
Instigators or others "egging on" the incident
List Any Witnesses
Preferably Credible Sources
What actions have you taken in response to the harassment? *
Comments, E-mails, Texts, Postings etc.
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)
PLEASE PRINT A COPY FOR YOUR RECORDS!
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