SPS Complaint of Bullying Form
Suffolk Public Schools students, either individually or as a part of a group, shall not harass or bully others. Prohibited conduct includes, but is not limited to, physical intimidation, taunting, name-calling, and insults and any combination of prohibited activities. Prohibited conduct includes verbal conduct consisting of comments regarding the race, gender, religion, physical abilities or characteristics or associates of the targeted person. The principal and staff of Suffolk Public Schools are committed to addressing complaints of bullying and will respond promptly and appropriately to such complaints. Any student can complain about bullying by talking to an administrator and/or completing this form and returning it to an assistant principal or principal.
*This survey was adapted from Southeast Polk High School Bullying/Harassment Reporting Form.
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First Name of person reporting:
Last Name of person reporting:
Booker T. Washington Elementary School
Creekside Elementary School
Elephant's Fork Elementary School
Florence Bowser Elementary School
Hillpoint Elementary School
Kilby Shores Elementary School
Mack Benn Jr. Elementary School
Nansemond Parkway Elementary School
Northern Shores Elementary School
Oakland Elementary School
Southwestern Elementary School
Col. Fred Cherry Middle School
Forest Glen Middle School
John F. Kennedy Middle School
John Yeates Middle School
King's Fork Middle School
King's Fork High School
Lakeland High School
Nansemond River High School
Turlington Woods School
College and Career Academy at Pruden
How can we contact you if needed?
Phone number or email address...
Age of person reporting:
First Name of victim:
Last Name of victim:
Date of incident:
Give the approximate date and time the incident occurred.
Location of the incident:
Before/After School sponsored activity
Away from school
Nature of Discrimination or Harassment:
Type of Harassment:
Electronic communication (cyber bullying)
Social/Relational (excluded from group...)
Description of the incident:
Provide a detailed description of what happened and/or what was said.
Name of witnesses (if any):
Any other information:
Include reference to evidence you may have including text messages, posters, pictures...
How often has this issue occurred?
This was the first time
3 times or less
4 times or more
Was this issue previously reported?
Please enter the name of who this issue was previously reported to in the Other information field.
No, this is the first time reporting.
Previously reported to bus driver
Previously reported to teacher
Previously reported to counselor
Previously reported to administrator
Previously reported to parent
I agree that all of the information is accurate and true to the best of my knowledge:
NOTE: All complaints will be followed by an investigation. Those accused as well as the parents of students involved will be informed of complaints, witnesses will be interviewed, and all information will remain confidential except for that which must be shared as part of the investigation. By clicking yes below, you are verifying that your statements are true and exact to the best of your knowledge.
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This form was created inside of Suffolk Public Schools.