Bullying and/or Cyberbullying Investigation and Reporting Form
In order for behavior to be considered bullying it has to be (1) repeated and (2) on purpose. Has the behavior your reporting been repeated and on purpose? If not, discuss the situation with the teacher, dean, or building administrator.
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Name
Grade
Date
School
List the name of the alleged bully and/or cyberbully. If name is not known, provide any other identifiable information:
Relationship between you and the alleged bully and/or cyberbully:
Describe the incident:
Where and when did it happen?
Were there any witnesses?
Clear selection
If yes, who?
Other information, including previous incidents or threats:
Student or parent declines to complete this form: 
Initial and Date on the line below. 
Signature
I certify that all statements made in the complaint are true and complete. Any intentional false statement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary in pursuing the investigation. 
Date
MM
/
DD
/
YYYY
Submit
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