Bullying Incident Report Form
If you have been the target of bullying or have witnessed the bullying of a District student, complete this form and submit it to alert the appropriate personnel. Paper forms of this copy are available in the counselor's office. Reports of bullying will be investigated and disciplinary action will be taken as warranted.
What is your name? (optional)
Students have the right to complete this form anonymously. However, it will be easier for the District to investigate this matter if as much information as possible is provided.Submission of a good faith will not have a negetive effect on future employment, grades, learning, or working environment of the person submitting the report. A complainant that falsely accuses someone will be subject to disciplinary action.
Your answer
You are a: *
Date of the alleged bullying: *
Your answer
Time of the alleged bullying: *
Your answer
Name of the student(s) subjected to bullying: *
Your answer
Person(s) alleged to have committed the bullying or harassment: *
Your answer
Summarize the incident(s) or occurrence(s) of bullying as accurately as possible. *
Your answer
Names of witnesses (if any):
Your answer
Have you reported this to anyone else? *
If you have reported it to someone else, who did you report to?
Your answer
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This form was created inside of New Franklin R-1 Schools.