Report Bullying
This form will be sent automatically to administrative personnel upon submission.
Date of Incident: *
Time of Incident: *
Repeat Infraction? *
Location of Incident (Mark all that apply): *
Name of Victim(s): *
Your answer
Name of Student(s) Bullying: *
Your answer
Name of Witnesses/Bystanders: *
Your answer
Bullying Behaviors (Mark all that apply): *
Describe the Incident: *
Your answer
Is there any Physical Evidence? *
Please submit any evidence if possible.
This can be emailed directly to and/or, mailed to the school, or dropped off to the school office.
Indicate who is making this report: *
Name of person filing report:
Your answer
Reports may be made anonymously, but disciplinary action may not be possible solely on the basis of an anonymous report.
Thank you for reporting this incident!
Please note that any false reporting will result in disciplinary action.
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