Bully/Safety Report Form
NPUSC Bully/Safety Hotline 574-654-0471 or 219-778-1483
Person Completing this Form *
Required
Which is your concern? *
Required
Email
Your answer
School of Concern *
Required
Have you previously reported an incident involving this person? *
Required
If you have spoken to a school employee about this, please list whom.
Your answer
Where did the incident happen? Please be specific, including dates, times, and location(s). *
Your answer
Who are you, or someone you know, having problems with? *
Your answer
Date of incident - As close as possible
MM
/
DD
/
YYYY
Please list any witnesses (first and last names)
Your answer
Is this a repeated behavior? *
Required
Were you (or someone else) targeted? *
Required
Was the incident unprovoked? Was it one-sided (you didn't start it or say anything in retaliation)
How are you (or someone else) being harassed/intimidated or what type of incident is this?
Please explain the incident or safety concern below. Please be specific. *
Your answer
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