Bullying Incident Report Form
If you have been the target of bullying or have witnessed the bullying of a Smithton student, complete and submit this form. Complaints against building principals should be submitted to the Superintendent. Complaints against the Superintendent should be submitted to the Board of Education. Reports of bullying will be investigated and disciplinary action will be taken as warranted. Students have the right to complete this form anonymously. However, it will be easier for the District to investigate this matter if as much information as possible is provided. Submission of a good faith complaint or report of bullying or harassment will not affect the complainant or reporter's future employment, grades, learning, or working environment. A complainant that falsely accuses someone will be subject to disciplinary action.
Date Filed
Your answer
Your Name
Your answer
Phone Number(s)
Your answer
Indicate the appropriate response to the following with a check mark(s). You are:
Date(s) of alleged bullying
Your answer
Name of student(s) subjected to bullying
Your answer
Person(s) alleged to have committed the bullying or harassment
Your answer
Summarize the incident(s) or occurrence(s) of bullying as accurately as possible.
Your answer
Name of Witnesses
Your answer
Have you reported this to anyone else?
If previously reported, please list person(s) with whom you told. If not previously reported then put "none".
Your answer
Submit
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