Report of Allegations of Bullying - Clear Creek Intermediate
Name of student making the report
Your answer
Date of Report
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Grade
Student ID #
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Parent/Guardian Name
Your answer
When did this happen? (Date/Time of Day)
Your answer
Are there immediate safety concerns?
If yes, please explain. If no, write N/A
Your answer
Name of person suspected of bullying and grade/teacher, if known:
Your answer
Bystanders/witnesses
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Where did this incident occur?
Description of bullying behaviors
Your answer
Specific concerns (check all that apply)
Required
Who was informed?
Required
List by name teachers or administrators that were notified.
Your answer
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