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: *
School *
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.
MM
/
DD
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YYYY
Time
:
Location of the incident: *
Required
Nature of Discrimination or Harassment: *
Required
Type of Harassment: *
Required
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? *
Was this issue previously reported? *
Please enter the name of who this issue was previously reported to in the Other information field.
Required
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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