Harassment, Intimidation & Bullying Reporting Form
Please use this form to report an incident of harassment, intimidation or bullying. Mrs. Bittner and Miss O'Donnell will be immediately notified and initiate an investigation.
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Email *
Person Reporting
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Name of Reporter *
Phone Number (optional)
Do you wish to remain anonymous?
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Name of Alleged Victim(s) *
Name of Alleged Offender(s) *
Date & Time of Incident *
Location *
Describe the nature of the alleged harassment, intimidation or bullying. Include names of people involved, what occurred and what each person said and did. Include specific words used. *
Why do you believe the incident occurred? *
Did a physical or emotional injury occur from the incident? If yes, please describe.
Was the alleged victim absent from school as a result of the incident? If yes, please indicate the number of days and specific reason for the absence.
List the names of any witnesses or anyone that may have relevant information. Please indicate the relationship of the witness to the alleged victim.
How did you learn of the incident?
I believe the discrimination was based on:
Please provide any other pertinent information that will assist in the investigation of this report.
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