Delphi Community Middle School Bullying/Harassment Report Form
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.
Today's Date *
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What time is it? *
Time
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Your Name:
(While this report can be filed anonymously, not leaving your name will make it harder to contact you if we need more information about what happened.)
Your answer
I am a: *
Describe what happened: *
Include information on the bully, the target, any witnesses/bystanders; the more detail provided the better.
Your answer
Location of event: *
Your answer
Date of incident: *
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Time of incident *
Time
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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 (Report Taker fills this part out.)
Your answer
Submit
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