Salisbury R-IV Online Bullying Incident Reporting 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 using the paper form. Complaints against the Superintendent should be submitted to the Board of Education using the paper form. Reports of bullying will be investigated and disciplinary action will be taken as warranted.
*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 affect the complaint or report's future employment, grades, learning, or working environment. A complaint that falsely accuses someone will be subject to disciplinary action.
You are a:
Date(s) / Time(s) of alleged bullying:
Name of the student(s) subjected to bullying:
Person(s) alleged to have committed the bullying / harassment:
Summarize the incident(s) or occurrence(s) of bullying as accurately as possible. Attach additional sheets or use the back side of this form, if necessary.
Name(s) of witnesses:
Type of Bullying
Physical: Hitting, pushing, kicking, damaging property or other physical aggression
Verbal: name-calling, put-downs, or other behavior that would hurt another's feelings
Emotional/Exclusion: Starting rumors or telling others not to be friends with someone
Cyber: Using any electronic device to bully
Have you reported this to anyone else:
If so, whom?
Submit report to:
Salisbury High School
Salisbury Middle School
Salisbury Elementary School
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