Bullying/Harassment Complaint Form
Bullying, cyberbullying, harassment, or intimidation are serious and will not be tolerated. This form is to report alleged bullying or harassment that occurred on school property, at a school-sponsored activity or event off school property, or on the way to/from school. If you are a student victim, parent/caregiver of a student victim, a close adult relative of a student victim, or staff member and wish to report an incident of alleged bullying, please contact the principal at the student’s school so the matter may be investigated. You may also complete this form and return it to the school site. (Ed. Code 234-234.5 & MUSD Board Policy 5131.2 & AR 5131.2)
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Email *
School Name or Location of Incident
Date and time of Incident
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Time
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Where Did the Incident Occur?
Type of of Bullying/Harassment that occurred?
Person(s) Alleged to have committed the Bullying or Harassment (First & Last Name, Age, Grade, School)
Name of Victim(s) (Who was the person being harmed, intimated, harassed or threatened?)
Are there any Witnesses? Please list all Names.
Description of the Incident: Use specific dates, times, location, names, etc. (Give as much information as possible.)
What is your Role?
What is your Name? (optional)-Please note: Anonymous reports are accepted, however, they must provide sufficient evidence to justify the commencement of an investigation.  Formal disciplinary action may not be based solely on an anonymous complaint.  
How to contact you (email/phone)
What is your relationship to the student victim?
How did you learn of the alleged bullying or harassment?
Was the student victim absent from school as a result of the incident? If yes, how many days was the student victim absent as a result of the incident?
Did a physical injury result?
Other Details: Anything else you like to add
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