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 to the building principal. Complaints against building principals should be submitted to the Superintendent. Complaints against the Superintendent should be submitted to the Board of Education. Reports of bullying will be investigated and disciplinary action will be taken as warranted. Once submitted, you will receive a copy of the submitted form.
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Email *
Name: *
Date *
MM
/
DD
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YYYY
Address: *
Phone Number: *
Relationship to the student being bullied:
 *
Did you witness this incident? *
If no, provide the specific information as to how you found out about this incident:
Date the incident took place: *
MM
/
DD
/
YYYY
Time the incident took place: *
Time
:
Which building did the alleged bullying take place: *
Name of student(s) subjected to bullying:
*
Person(s) alleged to have committed the bullying or harassment:
 *
Name(s) of any Witnesses:
Please describe the incident. (Include as much detail as possible. Do not "clean up"
anything that was said or done. If inappropriate language or gestures were used, include
the exact language and describe the exact gesture used.)
 *
Is there any other information you believe is relevant for the district to know when
investigating this incident?
 *
A copy of your responses will be emailed to the address you provided.
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