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Bullying/Harassment Incident Report or Witness Statement
Students and families- if you or someone you know are experiencing bullying of any kind inside our outside of school with another Summit Academy student, please report on this form.
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* Indicates required question
Email
*
Your email
Name of student being bullied/harassed
*
Your answer
Name(s) of accused individuals who bullied/harassed
*
Your answer
Where did the Incident Happen? Check all that apply
*
Classroom
Cafeteria
Hallway
Restroom
Gymnasium
Bus
To/From School
Not on school grounds (describe in notes)
Other (describe in notes)
Required
Describe in detail exactly what happened
*
Your answer
Describe any physical evidence that exists related to the incident- text/ email, websites, video/audio tapes, photos or other evidence.
Your answer
Name(s) of Witnesses
Your answer
Who did you tell at school?
Your answer
Name of person filling out this form
*
Your answer
Relationship to the person experiencing bullying/harassment
*
Self
Parent/Guardian
Witness
Required
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