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Bullying Report Form
If you have been the target of bullying or have witnessed the bullying of a District student, complete this form.

Bullying is defined as an unwanted, aggressive behavior that involves a real or perceived power imbalance to control or harm another person and is repeated over time.

Date Filed:
MM
/
DD
/
YYYY
Time:
Time
:
Name:
Your answer
Phone Number:
Your answer
You are a:
Dates of Alleged Bullying:
Your answer
Name of Student Subjected to Bullying:
Your answer
Person alleged to have committed the bullying or harassment:
Your answer
Summarize the incident or occurrence of bullying as accurately as possible. Include specific information such as location, time of day, persons involved, etc.
Your answer
Names of Witnesses:
Your answer
Have you reported this to anyone else?
If you have reported this to someone else, who did you report it to?
Your answer
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