Delphi Community Elementary School Reporting Form 
This information is confidential and will be shared with others only for investigation and follow-up purposes.

Please understand that providing your name is optional. However, without providing necessary information, it may be difficult to pursue this report.

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What is your FIRST name?
What is your LAST name?
Email or phone (if not a student)
I am a.... *
When did this happen?  (Date/Time) *
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DD
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YYYY
Time
:
Who was involved in this incident? Please provide first AND last name(s). *
Explain what happened: *
WHERE did this happen? *
If there were other people who witnessed this incident, please provide first AND last names.  If there were no witnesses, please type N/A or none. *
Have you told anyone else about what happened?  Who?
Definition of bullying: Overt, unwanted, repeated acts or gestures including verbal or written communications or images transmitted in any manner, physical acts of aggression, or any other behaviors that are committed by a student or group of students against another student with the intent to harass, ridicule, intimidate, or harm the other targeted student and create a hostile school environment for that student.  
Bullying is REPEATED, INTENTIONAL, and involves a real or perceived IMBALANCE of power.
Check all that apply:
 *
Required
Does the incident meet all 3 parts of the definition of bullying? (Mark only one) *
Is there anything else we should know? 
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