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Bullying Complaint Report Form
DISCLAIMER - Information from this form will be treated confidentially. We will only share this information with appropriate school personnel and law enforcement (if applicable.)
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* Indicates required question
Bullying is a harmful behavior that is repeated, intentional, and involves an imbalance of power.
Victim Information
Please enter information about the victim below.
Victim's Name
*
Your answer
Person Reporting Incident (Optional)
First and Last Name
Your answer
Phone Number of Person Reporting Incident (Optional)
xxx-xxx-xxxx
Your answer
Accused Information
Please enter information about the accused bully below.
Please enter information about the accused bully below.
*
Your answer
Location of Incident
*
Your answer
Date of Incident
*
MM
/
DD
/
YYYY
Time of Incident
Time
:
AM
PM
Possible reasons/alleged motives for the bullying incident:
*
Because of disability/ESE status
Because of gender
Because of gender identity
Because of imbalance of power
Because of marital/family status
Because of national origin
Because of physical appearance
Because of race/ethnicity
Because of religion
Because of sexual orientation
Just to be mean
The reason is unknown
Required
Describe what happened in as much detail as possible.
*
Your answer
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