Report a Bullying Incident
Completion of this Form is 100% confidential.  You will not be punished nor your identity revealed if you submit this Form with integrity.  If you feel that you or another student is in immediate danger please contact your school administrator or law enforcement.
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I am a: *
If you are a student, what grade are you in?
What is your name? (optional)
Which school do you attend? *
What is the name of the student(s) or other individual you would like to report? *
If you do not know the name(s), please describe the person(s).
Where did the incident take place? Be specific. *
When did the incident take place? Be specific. *
Please describe the incident with detail. *
How often has this happened? *
Were there witnesses to this incident? *
What are the names of the witnesses, if known?
Have you told an adult? If so, who and when? *
Please rate the severity of this incident from your perspective, 1 being a minor incident but unacceptable to 5 being a major incident that could result in retaliation or violence: *
Did this incident or person make you feel unsafe or afraid? *
Would you like to speak to a counselor? *
What else would you like us to know about this incident? (optional)
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