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Bullying Report Form
Bullying is a serious issue and will not be tolerated. Use this form to report bullying that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; on the way to and/or from school; on social media or through text message, during the current school year. If you are a student or a friend of a student is who is being bullied and wish to report an incident of bullying, complete this form.

While the form below may be submitted anonymously, it would be helpful to the investigation process to have the names of all people involved including the name of the person submitting the form.

We appreciate your assistance in helping us maintain a safe community of learning in the Clinton School District.

Your Name
Your answer
Date
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I am a:
Phone number (optional)
Your answer
Email address (optional)
Your answer
Student who was bullied:
Your answer
Student who did the bullying:
Your answer
Date and time of incident:
Your answer
Location of incident:
Your answer
Type of bullying being reported:
Did the bullying include mean comments about you or other students'?
Please give any other details about the incident that you feel are important.
Your answer
Were there any witnesses? If so, who?
Your answer
Are you afraid to come to school
Submit
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