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BULLYING INCIDENT REPORT FORM
If you have been the target of bullying or have witnessed the bullying of a Smithville student, complete this form; it will automatically submit it to Ms. Rachael Marchetti. Complaints against building principals should be submitted to the Superintendent. Complaints against the Superintendent should 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 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 knowingly falsely accuses someone will be subject to disciplinary action.

Name:
Your answer
Phone Number(s):
Your answer
Please select one of the following. You are a:
Date(s) of alleged bullying:
Your answer
Name of student(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?
If you answered "yes" to the question above, to whom have you reported this incident?
Your answer
Submit
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