Speak Up Promote Respect - Incident Report
We encourage you to report bullying or other inappropriate behaviors.  Once you complete the form below, you will receive a confirmation that your information has been submitted.  Designated school personnel will be alerted and respond to your report during regular school hours.  Individuals who submit information will NOT be identified but may be contacted if there are additional questions about the incident.  If this is an emergency, dial 911.

As a Reminder:  According to the code of Virginia, Bullying is defined as any aggressive and unwanted behavior that is intended to harm, intimidate, or humiliate the victim; involves a real or perceived power imbalance between the aggressor or aggressors and target; and is repeated over time or causes severe emotional trauma.  Bullying includes cyber bullying.  Bullying does not include ordinary teasing, horseplay, argument, or peer conflict.

*NOTE:  False reports made will be taken very seriously and may result in disciplinary action*
Sign in to Google to save your progress. Learn more
Email *
Date of Incident: *
Name of person filing report (you will NOT be identified-this is only in case we have any additional questions) *
School of Alleged Target *
Schools are alphabetized by level.
Relationship to the Target *
What is the best way to reach you: *
Please share your phone / email address or other contact information (the best way to reach you.) *
Who is your school counselor? *
How do you know about the behavior? *
Identify the student(s) Involved in the bullying -The aggressor(s) *
Identify the student(s) who were the target of the bullying *
Bystanders: Did anyone else observe the behavior / incident?  Please name the individual(s) if you can. *
Date and time of incident (i.e. Thursday, May 1, during 2nd block right after lunch)  Please be as specific as possible as we may need to increase supervision in an area. *
Where did the incident occur? *
Type of Bullying Behavior You are Reporting *
Please describe the incident in as much detail as possible *
How often has this happened? *
I understand school phones, email accounts, and this report will be monitored ONLY during regular school hours on days when school is in session for students.  While the average response time should be within one school day, please be aware that it may take two school days for a school official to contact you and follow up.  The safety and well-being of students is a community concern, and ther are a number of community supports in place.  If you have a life-threatening mental health emergency, call 911.  If you have knowledge of a crime that has been committed, contact the Chesterfield County Police at 804-748-1251.  If you have information about a serious mental health related concern, contact the Chesterfield County Crisis hotline at 804-748-6356. *
I understand this information will remain confidential *
A copy of your responses will be emailed to the address you provided.
Clear form
Never submit passwords through Google Forms.
This form was created inside of Chesterfield County Public Schools. Report Abuse