Stuttgart Schools Incident of Bullying Report Form
 Bullying - the intentional harassment, intimidation, humiliation, ridicule, defamation, or threat or incitement of violence by a student against another student or public school employee by written, verbal, electronic, or physical act that may address an attribute of the other student, public school employee, or person with whom the other student or public school employee is associated and that causes or creates actual or reasonably foreseeable: a) physical harm to a public school employee or student or damage to the public school employee’s or student’s property; b) substantial interference with a student’s education or with a public school employee’s role in education; c) a hostile educational environment for one (1) or more students or public school employees due to the severity, persistence, or pervasiveness of the act; or d) substantial disruption of the orderly operation of the school or educational environment.
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Person Reporting Incident  *
Telephone  *
Name of Student Victim  *
Name of the school the child attends *
Grade  *
Your Relationship to Victim *
Date of Incident  *
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Time of Incident  *
Time
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Location of Incident *
What did the alleged offender say or do (be specific and quote the words used)? *
Do you have any evidence you can give to show what happened? *
Please list the first and last name of any witnesses  *
Has the victim missed any school as a result of the incident? *
Has this occurred before with this offender? *
If you answered "yes" above, did you report it? *
If you answered "yes" above, who did you report it to?
I hereby certify that the information I have provided in this complaint is true, correct, and complete.  Please type your name below.  *
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