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Report of Suspected Bullying or Harassment
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Name of Reporter
Leave blank for anonymous
Your answer
Target(s) of Behavior
Your answer
Relationship of Reporter to Target
i.e. peer, parent, self, etc.
Your answer
Report Filed Against
Perpetrator's name
Your answer
Date(s) of Incident(s)
Your answer
Location(s)
Your answer
Time
if applicable
Time
:
AM
PM
Describe the basis for your report. Include information about the incident(s), participants, background to the incident, and any attempts you have made to resolve the problem. Please note relevant dates, times and places.
Your answer
Based upon information provided, are there any other district policies implicated?
Yes
No
Other:
Clear selection
Explain.
Your answer
Indicate if there are witnesses who can provide more information regarding your report. If the witnesses are not school district staff or students, please provide contact information.
Your answer
Have there been previous incidents?
Yes
No
Clear selection
If “yes”, please describe the behavior of concern, the approximate dates and the location:
Your answer
Were these incidents reported to school employee(s)?
Yes
No
Clear selection
If “yes”, to whom were they reported and when?
Your answer
Was the report written or verbal?
Written
Verbal
Clear selection
Submit
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