JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Harassment, Intimidation, Hazing & Bullying Report
Sign in to Google
to save your progress.
Learn more
* Required
Optional Information
First Name
Your answer
Last Name
Your answer
Email
Your answer
Phone
Your answer
Incident Information
Date of the Incident
MM
/
DD
/
YYYY
Time of the Incident
Time
:
AM
PM
If date and/or time of the incident are unknown, if possible, please give a general timeframe for the incident.
Your answer
School
*
Choose
Amelia
Clough Pike
Holly Hill
Merwin
Summerside
Willowville
Withamsville-Tobasco
West Clermont Middle School
West Clermont High School
Unknown
Location
*
Bathroom
Bus
Cafeteria
Classroom
Extraccurricular Activity
Gym
Hallway
Locker
Parking Lot
Playground
Unknown
Other:
Required
Please enter more information about the location of the incident to assist in identifying where the incident occurred.
*
Your answer
Your Role
*
Choose
Administrator
Bystander
Parent/Caregiver
Staff Member
Teacher
Student
Volunteer
Please enter any other information about how you were involved or how you know of this incident.
*
Your answer
Type / method of harassment, intimidation, hazing, or bullying
*
Physical
Verbal
Social
Cyber
Other:
Required
Please enter as much information as possible about the type / method of harassment, intimidation, hazing, or bullying you are reporting (e.g., electronic communication, written communication, relationship / dating).
*
Your answer
Cause of harassment, intimidation, hazing, or bullying:
*
Age
Color
Race
Creed
National Origin
Ancestry
Marital Status
Sex
Religion
Gender Identity
Physial Attributes
Physical/Mental Abilities
Political Belief
Political Party Preference
Unknown
Other:
Required
Name(s) of the person being harassed, intimidated, hazed, or bullied?
*
Your answer
Victim's Age
*
Choose
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Unknown
Adult
Victim's Grade
*
Choose
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Uknown
Adult
Who was harassing, intimidating, hazing, or bullying?
*
West Clermont Student
Student From Another District/School
Staff Member
Volunteer
Other:
Offender(s) Name
*
Your answer
Offenders Age
*
Choose
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Unknown
Adult
Offender's Grade
*
Choose
PK
K
1
2
3
4
5
6
7
8
9
10
11
12
Uknown
Adult
Please provide as much information as possible about the incident, including names of witnesses and exactly what happened.
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of West Clermont Local Schools.
Report Abuse
Forms
