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Bullying Reporting Form
Dignity for all students (Bullying, Harassment and Hazing)
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Date of Incident

Name (s) of alleged offender(s) (Bully) if known:
Name (s) of victim (s) : *
Name (s) of possible witnesses/bystanders:
Description of Incident:  *
When did this happen? Is it the first time?
Did physical injury result from this?
Name of person reporting incident ( may be anonymous).  If you leave your name you will be contacted by Mr. Swick ( Principal or Mrs. Dornburgh ( DASA Coordinator as soon as possible.  
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