Bullying Report Form 
This report is to be completed by the individual making or receiving a report of alleged bullying or harassment. The administrator will respond to this form when receiving a report of alleged bullying or harassment from a student. 

"Bullying" Means a single significant act or a pattern of acts by one or more students directed at another student that exploits an imbalance of power and involves engaging in written or verbal expression, expression through electronic means, or physical conduct that satisfies the applicability requirements below and that:

Has the effect or will have the effect of physically harming a student, damaging a student's property, or placing a student in reasonable fear of harm to the student's person or of damage to the student's property;

Is sufficiently severe, persistent, or pervasive enough that the action or threat creates an intimidating, threatening, or abusive educational environment for a student;

Materially and substantially disrupts the educational process or the orderly operation of a classroom or school; or

Infringes on the rights of the victim at school;

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Email *
Email: *
 Name of Person Completing Form: *
Alleged Target Student's Name:

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Alleged Perpetrator's Name(s):

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Name(s) of Witness(es) to Alleged Conduct:
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Date(s) of Incident or Event(s):

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MM
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DD
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YYYY
Time of Incident:
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Location of Incident:
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Description of Incident or Event(s): *
Was the incident reported to anyone else?

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Required
When was the Incident or Event(s) reported?

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MM
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DD
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YYYY
Who was the Incident or Event(s) reported to?

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What was done when you reported the Incident or Event(s)?

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Please include other information including prior incidents or threats:

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