Online Harassment or Bullying Reporting Form
This form is used to report bullying or harassment incidents.
Directions
Harassment and bullying are serious and will not be tolerated. If you are a student, the parent/guardian of a student, a volunteer or visitor, and wish to report an incident of alleged harassment and/or bullying, complete and submit this form. Upon submission the Principal and Dean of Students will be notified. All school employees are required to report alleged violations. Contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting the "Name of Person Reporting the Incident" field.
Please Read:
Harassment, intimidation, and bullying are serious and will not be tolerated.

State law defines harassment, intimidation, or bullying as follows:

(a) any intentional written, verbal, electronic, or physical act that a student has exhibited toward another particular student more than once and the behavior both (i) causes mental or physical harm to the other student; and (ii) Is sufficiently severe, persistent, or pervasive that it creates an intimidating, threatening, or abusive educational environment for the other student.

or

(b) violence within a dating relationship.

If you are a student, the parent/guardian of a student, a volunteer or visitor, and wish to report an incident of alleged harassment and/or bullying, complete and submit this form. Upon submission the Principal and Dean of Students will be notified. All school employees are required to report alleged violations. Contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting the "Name of Person Reporting the Incident" field.

Confidentiality: We are committed to maintaining the confidentiality to the extent legal and appropriate about facts discovered, persons involved, and discipline implemented, if any. This is to protect the privacy of all persons involved.

Retaliation: We prohibit any reprisal or retaliation against any person or victim reporting harassment, intimidation, or bullying.

Name of Alleged Victim *
Your answer
Name of Alleged Offender(s) *
If you do not know, please put whatever information you can.
Your answer
What Grade is the Alleged Offender in? *
On what date did the incident happen? *
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YYYY
If there are multiple incidents, please select additional dates.
MM
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YYYY
If there are multiple incidents, please select additional dates.
MM
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DD
/
YYYY
Where did the incident happen (choose all that apply)? *
Required
Select the statement(s) that best describes what happened (choose all that apply): *
Required
What did the alleged offender(s) say or do? *
Your answer
Did a physical injury result from this incident? *
Was the student victim absent from school as a result of the incident? *
If Yes, how many days was the student victim absent from school as a result of the incident?
Your answer
Is there any additional information you wish to provide?
Your answer
Select from the choices below to best describe yourself: *
Is there any additional information you wish to provide or answers on this form you wish to clarify?
Your answer
THE FOLLOWING SECTION IS OPTIONAL. DO NOT FILL OUT THIS SECTION IF YOU WISH TO REMAIN ANONYMOUS.
Your name
Your answer
Your Telephone Number
Your answer
Your E-Mail
Your answer
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