CBMS Student Harassment & 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 teachers and staff at Central Baldwin Middle School in investigating these reported incidents of such behavior.
PERSON REPORTING INCIDENT
*
Your answer
Grade *
Homeroom Teacher *
Your answer
INFORMATION REGARDING INCIDENT
Name of alleged student victim *
Your answer
Name(s) of alleged offender(s), if known:
Your answer
Is the alleged offender(s) a student at CBMS? *
Name(s) of alleged witness(es), if known:
Your answer
On what date(s) did the incident happen? *
MM
/
DD
/
YYYY
Where did the incident happen? (Please choose all that apply).
Select the statement(s) that best describes what happened. (Please choose all that apply). *
Required
Describe the incident(s), including what the alleged offender(s) said or did *
Your answer
Did a physical injury result from this incident? *
Required
Is there any additional information that you would like to provide?
Your answer
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