Bullying Report Form
Please complete this form to report an incident of bullying to Middlebury Community School administrators. Remember, bullying is defined as "someone repeatedly and on purpose saying or doing mean or hurtful things to another person who has a hard time defending himself or herself." Bullying is NOT mutual peer conflict, horseplay or fighting.
Name of Person Completing Report
*May remain anonymous if you wish, but it is helpful for investigative purposes if we know who is making the report
Date of Incident
Time of the Incident
What school does the student attend?
Northridge High School
Northridge Middle School
Heritage Intermediate School
Jefferson Elementary School
Middlebury Elementary School
Orchard View Elementary School
York Elementary School
Location of the Incident
Description of the Incident
*Please provide as much information as possible (who, what, why, etc.). Include actions and words said or observed. If the incident is of an electronic nature, include copies if possible.
This report was created to record incidents of bullying involving students of Middlebury Community Schools. After a report is completed, an administrator and/or School Resource Officer will conduct an investigation and any necessary follow-up. Thank you.
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