SHS Anonymous Potential Bullying/Harassment Incident Reporting Form
Please complete this form to report an incident/situation that you suspect may involve bullying and/or harassment. Once this form is submitted, we will investigate the incident to determine the facts of the situation and ensure the safety of all of our students.
Name of person making report (optional)
Your answer
Indicate whether you are the: *
Indicate whether you are a: *
Phone number of reporter (optional)
Your answer
Is the reported target a: *
Please provide the name or description of aggressor: *
Your answer
Is the aggressor a: *
Date(s) of Incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Location of the incident *
Your answer
Witness #1
Your answer
Is witness #1 a:
Witness #2
Your answer
Is witness #2 a:
Please DESCRIBE the details of the incident in the space below. Be sure to INCLUDE the names of all the parties involved, what occurred, who did what to whom and include specific words/threats and/or language used. *
Your answer
Submit
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