Bullying, Harassment, or Intimidation Reporting Form
Please complete the following form to report incidents of alleged bullying. Please note that it may take up to 4 days to receive a response regarding the report.
Sign in to Google to save your progress. Learn more
Today's Date *
MM
/
DD
/
YYYY
Person Reporting the Incident *
Telephone Number *
Please check the appropriate box regarding the person reporting the incident. *
Required
Enter the name(s) of the alleged targeted student(s). (if known) *
Enter the name(s) of the alleged offender(s) (if known) *
Enter the name(s) of alleged witness(es) (if known)
Enter the date(s) the incident(s) occurred. (month/date/year) *
Check the statement(s) that best describe what happened (choose all that apply).
Where did the incident happen? (Check the statement; check all that apply) *
Required
Describe the incident(s), including what the alleged offender(s) said or did. *
Why do you think the bullying, cyberbullying, harassment, and/or intimidation occurred.
Did a physical injury result from this incident? Mark next to one of the following:
Clear selection
Was the student victim absent from school as a result of the incident?
Clear selection
Is there any additional information you would like to provide?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Ashland Elementary School.

Does this form look suspicious? Report

Google Forms