Bullying/Harassment Complaint Form
(Students May Report Anonymously)
Email address *
Date Filed: *
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First and last name of student being bullied/harassed:
Your answer
School Site of student being bullied/harassed: *
Address of student being bullied/harassed:
Your answer
Phone # of student being bullied/harassed:
Your answer
Please identify yourself:
Please check the type of bullying that has occurred (more than one can be checked):
Bullying/Harassment on the basis of:
Dates of alleged bullying or harassment
Your answer
Person(s) alleged to have committed the bullying or harassment:
Your answer
Description of the incident: If possible, use specific dates, times, locations, names, etc.
Your answer
Names of witnesses:
Your answer
Have you reported this incident to anyone else:
If yes, who did you report the incident to:
Your answer
Name of Reporting Person *
Your answer
Date: *
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A copy of your responses will be emailed to the address you provided.
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