BULLYING, HARASSMENT, OR INTIMIDATION REPORTING FORM
Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report 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*, in the current school year. 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 this form. Contact the school for additional information or assistance at any time.

Bullying, harassment, or intimidation means intentional conduct, including verbal, physical, or written conduct, or an intentional electronic communication, that: (I) creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being and is: 1. motivated by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attribute, socioeconomic status, familial status, or physical or mental ability or disability; or 2. threatening or seriously intimidating; and (II) 1. occurs on school property, at a school activity or event, or on a school bus; or 2. substantially disrupts the orderly operation of a school. Electronic communication means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager.
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School *
Person Reporting Incident Name *
Person Reporting Incident Telephone *
Person Reporting Incident E-Mail *
Place a check in the appropriate box: *
Who is the reporter?
Required
Name of Student Victim *
Age of Student Victim *
Name of Alleged Offender 1 *
Age of Alleged Offender 1 *
Is Alleged Offender 1 a student? *
School Attended by Alleged Offender 1 *
Name of Alleged Offender 2
if applicable
Age of Alleged Offender 2
if applicable
Is Alleged Offender 2 a student?
Clear selection
School Attended by Alleged Offender 2
if applicable
Name of Alleged Offender 3
if applicable
Age of Alleged Offender 3
if applicable
Is Alleged Offender 3 a student?
Clear selection
School Attended by Alleged Offender 3
if applicable
On what date(s) did the incident happen? *
Where did the incident happen? *
Choose all that apply
Required
Place a check next to the statement(s) that best describe what happened: *
Choose all that apply
Required
What did the alleged offender(s) say or do? *
Why did the harassment or intimidation (bullying) occur? *
Did a physical injury result from this incident? Place a check next to one of the following: *
Required
If there was a physical injury, do you think there will be permanent effects? *
Required
Was the student victim absent from school as a result of the incident? *
Required
If yes, how many days was the victim absent as a result of the incident? *
Did a psychological injury result from this incident? Place a check next to one of the following: *
Required
Is there any additional information you would like to provide?
Submit
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