Discrimination, Harassment, or Bully Reporting Form
The faculty and staff at Centennial Academy are committed to eliminating all incidents of bullying, harassment, or discrimination. The purpose of this form is to assist any school stakeholder who feels wrong doings have occurred. The school relies on timely and accurate information from parents and students to properly address and solve these concerns.

Please provide detailed information in the form below. Additionally, you are invited to contact the appropriate Dean of Students to ensure that all complaints have been resolved.

We appreciate your efforts in helping Centennial Academy maintain the best possible academic and social environment for all.

First and Last Name Alleged Target *
Your answer
First and Last Name of Alleged Aggressor *
Your answer
Has this incident been reported to anyone before? *
If yes, to whom? When?
Your answer
Location *
Date of Incident *
MM
/
DD
/
YYYY
How many times has this student been targeted by the aggressor? *
How long has this been happening?
Type of Event (Select all that apply.) *
Required
Describe events (Please be specific.) *
Your answer
This incident is related to the targeted student's: (Check all that apply) *
Required
List other students/staff who witnessed the event. If none, type N/A. *
Your answer
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