Delphi Community Middle School Bullying/Harassment Report Form
Delphi Community School Corporation maintains a firm policy prohibiting all forms of bullying. Everyone is to be treated with respect and dignity. Bullying by any student, teacher, administrator, or other school personnel which creates an intimidating environment will not be tolerated under any circumstances.

Please use this form to report issues relating to bullying, cyber-bullying, racism, or other forms of harassment.

This information is confidential and will be shared with others only for investigation and follow-up purposes.

Please understand that all these questions are optional. However, without providing necessary information, it may be difficult to pursue this report.

All information included in this report is CONFIDENTIAL!!
(You can choose to include your name or not. Please understand that if you do not leave your name and we need more information, we will not have any way to contact you.)
Your Name:
Your answer
I am a:
Describe what happened:
Include information on the bully, the victim, any witnesses/bystanders; the more detail provided the better.
Your answer
Location of event:
Your answer
Date/Time of event:
Your answer
What sort of help would you like with this issue?
Your answer
Have you told anyone else about this incident? Who?
Your answer
Additional Information:
Your answer
For OFFICE USE ONLY
Please record the steps taken and update as needed.
Disposition
Your answer
Submit
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