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PC Bullying, Harassment or Intimidation Reporting Form
2021-2022
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* Indicates required question
Today's Date
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MM
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DD
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YYYY
Name of student victim
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Your answer
Age of student victim
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Your answer
Grade of student victim
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3rd Grade
4th Grade
5th Grade
Name(s) of alleged offender(s) (if known)
Your answer
Alleged offenders school (if known)
Indian Valley Elementary School
Pinecrest School
Nichols Lawson Middle School
Sylacauga High School
Clear selection
Where did the incident occur (choose all that apply)?
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On school property
On school bus
At a school sponsored activity or event off school property
On the way to/from school
Other
Required
Choose the statement(s) that best describes what happened (choose all that apply)
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Any bullying, harassment, or intimidation that involves physical aggression
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means
Demeaning and making the victim of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating (bullying), extorting, or exploiting
Spreading harmful rumors or gossip
Electronic communication (specify)
Other (specify below)
Required
If you chose Electronic communication or Other in the previous question, please specify.
Your answer
What did the alleged offender(s) say or do?
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Your answer
Do you have any information to share about why the bullying, harassment or intimidation occurred?
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Your answer
Is there any additional information you would like to provide (ex. threats of suicide, legal issues, etc.)?
Your answer
Person reporting incident contact number
Your answer
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