MSD: Bullying Complaint Form
This form is to document alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored activity or event off school property, on a school bus, or on the way to and/or from school.

If you are a student victim, the parent/guardian of a student victim, or a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying, harassment, or intimidation, complete and submit this online form. The form will be reported to the Principal of the School, but feel free to contact the school for additional information or assistance at any time.

Please be aware that intentionally making a false report or retaliation against any person who reports, is thought to have reported, files a complaint, or otherwise participates in an investigation or inquiry concerning allegations of bullying is prohibited may result in disciplinary action.

Date of the incident:
MM
/
DD
/
YYYY
School at which the incident happened:
Person reporting the incident:
Your answer
Telephone Number:
Your answer
Email Address:
Your answer
Please select the appropriate box, are you:
Name of alleged victim:
Your answer
Grade/Age:
Your answer
Name of alleged offender(s) if known:
Your answer
Where did the incident happen (please choose all that apply):
Required
Witness(es) present:
Your answer
Physical evidence
Please identify the statement(s) that best describes what happened (choose all that apply):
Required
Please state any additional concerns, descriptions, or details below (i.e., what did the alleged offender(s) say or do? How did it make you feel?)
Your answer
What is the nature of this incident?
Submit
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