BULLYING INCIDENT REPORT FORM

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If you have been the target of bullying or have witnessed the bullying of a District student, complete this form and submit to the building principal. Complaints against building principals should be submitted to the Superintendent. Complaints against the Superintendent should be submitted to the Board of Education. Reports of bullying will be investigated and disciplinary action will be taken as warranted.

Email *

Record my email address with my response

Date *

YYYY

Name *

Indicate the appropriate response to the following with a check mark(s): *

Student

Parent

Employee

Substitute

Date(s) of alleged bullying: *

YYYY

Names of those involved *

Name of Student(s) who did the bullying or harassment? *

Summarize the incident(s) or occurrence(s) of bullying as accurately as possible. *

Names of Witnesses: *

Have you reported this to anyone? *

Yes

If yes, who?

Send me a copy of my responses.

Submit

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