Online Bullying Report Form
This form is to document alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored activity or event off school property, on a school bus, or on the way to and/or from school.

If you are a student victim, the parent/guardian of a student victim, or a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying, harassment, or intimidation, complete and submit this online form. The form will be reported to the Principal, Assistant Principal, and School Counselor, but feel free to contact the school for additional information or assistance at any time.
Name (Optional):
Email (optional):
Today's Date: *
Who is reporting? *
Name of Student being Bullied: *
Grade Level of Student being Bullied: *
Name of student(s) bullying: *
Grade level of Student bullying: *
When did the bullying happen? (List specific dates and times if possible) *
Where did the incident happen? *
Describe the bullying incident(s): *
Witness(es) Present:
What do you recommend Administration do to help resolve the problem? *
Do you want Administration to talk to you *
If you would like Administration to talk with you, please give your name and grade:
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