Allegations of Bullying
Today's Date *
MM
/
DD
/
YYYY
School: *
Person Reporting Incident/s (may report anonymously):
Reporting person is a: *
Contact Information:
(ie., phone, email
Date/s Incident Occured
MM
/
DD
/
YYYY
Name of victim of the bullying incident (student being bullied): *
Type of bullying (check all that apply); *
Required
Brief explanation of incident: *
Where did the bullying happen? *
Example: hallway, playground?
Did a physical injury result from this incident? *
Required
Medical attention required:
Are you aware if the victim missed any school as a result of this incident?
If yes, how many days was the student absent as a result of this incident?
Any other information that may be helpful in our investigation.
Note: The school district is not authorized to disclose to a target, private educational or personnel data regarding an alleged perpetrator who is a student or employee of the school district. School officials will notify the parent(s) of all students involved in a bullying incident and the remedial action taken, to the extent permitted by law, based on a confirmed report.
OFFICE ONLY:
Person receiving report:__________________________________
Submit
Never submit passwords through Google Forms.
This form was created inside of Muncie Community Schools. Report Abuse