Bullying/Harassment Complaint Form
(Students May Report Anonymously)
First and last name of student being bullied/harassed:
School Site of student being bullied/harassed:
Address of student being bullied/harassed:
Phone # of student being bullied/harassed:
Please identify yourself:
Please check the type of bullying that has occurred (more than one can be checked):
Verbal Abuse (name-calling, racial remarks, belittling, etc. Can be done over the phone, in writing, in person, text, email)
Physical (hitting, kicking, shoving, twisting limbs, spitting, or destroying personal belongings)
Extortion (verbal or physical bullying for money or personal time)
Hazing (having to participate in an act of physical or emotional harm to be part of a group, or are a victim of a group)
Indirect Bullying (rejection, exclusion, ignoring, alienating, or isolating to purposely cause emotional distress)
Cyberbullying (using technology to harass, threaten, or target another person - text, IMs, email, Facebook, videos, MySpace, Twitter, etc.
Bullying/Harassment on the basis of:
Race, color or nationality
Gender or Gender Identity
Dates of alleged bullying or harassment
Person(s) alleged to have committed the bullying or harassment:
Description of the incident: If possible, use specific dates, times, locations, names, etc.
Names of witnesses:
Have you reported this incident to anyone else:
If yes, who did you report the incident to:
Name of Reporting Person
A copy of your responses will be emailed to the address you provided.
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