Report of Suspected Bullying or Harassment
Sign in to Google to save your progress. Learn more
Name of Reporter
Leave blank for anonymous
Target(s) of Behavior
Relationship of Reporter to Target
i.e. peer, parent, self, etc.
Report Filed Against
Perpetrator's name
Date(s) of Incident(s)
if applicable
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.
Based upon information provided, are there any other district policies implicated?
Clear selection
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.
Have there been previous incidents?
Clear selection
If “yes”, please describe the behavior of concern, the approximate dates and the location:
Were these incidents reported to school employee(s)?
Clear selection
If “yes”, to whom were they reported and when?
Was the report written or verbal?
Clear selection
Clear form
Never submit passwords through Google Forms.
This form was created inside of Region 4 Schools. Report Abuse