STUDENT HARASSMENT AND BULLYING COMPLAINT FORM
The Alabama State Department of Education requires each school system to establish a procedure for the investigation of all incidents reported to school officials of harassment, violence, threats of violence, or intimidation by any other student. This form will assist schools in the Baldwin County Public School System in investigating these reported incidents of such behavior.
What is your name?
Name of alleged student victim (who is being bullied)
Name(s) of alleged offender(s), if known. (Who is bullying someone)
Name of alleged witness(es), if known: (who saw it)
When did the incident happen? What date, and what time of day?
Where did the incident happen?
On a school bus
At a school-sponsored activity or event off school property
Via Internet—sent on school property
Via Internet—sent off school property
Place a check next to the statement(s) that best describe(s) what happened. (Choose all that apply.)
Any bullying, harassment, or intimidation that involves physical aggression
Hitting, kicking, shoving, spitting, hair pulling, or throwing something
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 the object of jokes
Making rude and /or threatening gestures
Intimidating (bullying), extorting, or exploiting
Cyberbullying (e.g., social media including Facebook, Twitter, Snapchat, Instagram, Kik, etc.)
Spreading harmful rumors or gossip
Sexual in nature
Related to the student’s perceived sexual orientation
Excluding or rejecting the student
Related to the student’s disability
Electronic communication (e.g., e-mail, text, sexting, etc.)
Describe the incident(s), including what the alleged offender(s) said or did.
Why did the bullying, harassment, or intimidation occur?
Did a physical injury result from this incident? (Check the appropriate box.)
Yes, and it required medical attention
Is there any additional information that you would like to provide? (Please print.)
I agree that all of the information on this form is accurate and true to the best of my knowledge
Never submit passwords through Google Forms.
This form was created inside of Baldwin County Schools.
Terms of Service