JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
USD 509 Harassment or Bullying Report Form (anonymous)
Please use this form to report any bullying or harassment event. When the "submit" button is activated, the report will be directed to a district official who will review the report and determine appropriate action.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date(s) of Incident
*
mm/dd/yyyy
Your answer
Time(s) of Incident
*
HH:MM AM or PM
Your answer
Nature of Complaint
*
What type of incident was the complaint?
Racial Harassment
Sexual Harassment
Physical Bullying (persistent pushing/shoving, making threats, defacing property, stealing, etc.)
Emotional Bullying (persistent name-calling, teasing, insulting, harassing phone calls, etc.)
Social Bullying (persistent gossiping, teasing about looks, excluding someone from groups, arranging public humiliation, etc.)
Cyber bullying (persistent texting/messaging threats, posting defamatory websites, emailing derogatory photos, etc.
Other:
Required
Place Where Incident Occurred:
*
South Haven Elementary School
South Haven Jr/Sr High School
Outside on Playground
Outside on Other School Grounds
On Bus
In School Hallway
Other:
Required
Alleged Bully or Harasser's Name(s)
*
Your answer
Alleged Victim's Name
Your answer
Description of Event
*
Describe the bullying or harassment event being reported to the best of your abiliity.
Your answer
Were there witnesses?
*
Please provide names, if yes.
Your answer
Name of Person Submitting Complaint (optional)
Name of person reporting the event (NOT REQUIRED)
Your answer
Email (optional)
Email address of person reporting the event (NOT REQUIRED)
Your answer
Phone Number (optional)
A phone number where the person submitting the complaint may be contacted
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of USD509.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
