Bullying Report Form
If you have been the target of bullying or have witnessed the bullying of a district student, complete this form. 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.
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Date *
MM
/
DD
/
YYYY
Name *
Phone Number(s)
You are a: *
Check the appropriate box.
Required
Date(s) of alleged bullying: *
Name of student(s) being bullied: *
Person(s) alleged to have committed 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 else? *
Required
If you answered yes to the question above, who have you reported it to?
Please sign your name by typing /s/ before your full name below. By signing your name you are confirming that the information given above is true to the best of your knowledge.
Example:  /s/Your Name
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