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Bullying Incident Report Form
If you have been the target of bullying or have witnessed the bullying of a District student, complete this form and submit to the building principal.

Complaints against building principals should be submitted to the Superintendent (not this form). 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.

Bullying, as defined by board policy, is strictly prohibited. Students are encouraged to report any incident of bullying which they have witnessed or incurred, by contacting the building principal. No employee or student who reports an act of bullying shall be subject to reprisal or retaliation for making such a report. Any person who engages in reprisal or retaliation against an employee or student who reports an act of bullying shall be subject to disciplinary action.

*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 falsely accuses someone will be subject to disciplinary action.

http://www.moconed.com/policy.php?action=ind&polID=1284&catID=3 (Bullying - Policy 2655)

Date Filed:
MM
/
DD
/
YYYY
Time:
Time
:
*Name:
Your answer
Phone Number:
Your answer
You are a:
Date(s) of alleged bullying:
Your answer
Name of student(s) subjected to alleged 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 so, who did you report to?
Your answer
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