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Winston Bullying Report
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 directly to the Superintendent. Complaints against the Superintendent should be submitted directly to the Board of Education.
Date Filed:
MM
/
DD
/
YYYY
Your Name:
Your answer
Students have the right to complete this form anonymously. However, it will be much easier for the District to investigate this matter if as much information as possible is provided. Any 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.
You are a:
Date(s) of alleged bullying
Your answer
Name of student(s) subjected to bullying
Your answer
Person(s) alleged to have committed the bullying or harassment.
Your answer
Please summarize the incident of bullying as accurately as possible
Your answer
Please list any witnesses
Your answer
Have you reported this to anyone?
If this has been previously reported, who did you report this to?
Your answer
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