Bullying Incident Report Form
If you have been the target of bullying or have witnessed the bullying of a District student, complete this form and submit to the building principal. 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.
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Your Name*:
Your answer
Phone Number(s):
Your answer
Indicate the appropriate response to the following with check mark(s):
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
Names of Witnesses:
Your answer
Have you reported this to anyone else:
Your answer
*Signature of Complainant:
Your answer
*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.
Your answer
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This form was created inside of Community R-VI Schools.