Bullying, Harassment or Intimidation Reporting Document
Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment or intimidation that occurred on school grounds, in a vehicle owned, leased, or contracted by the school being used for a school purpose by a school employee or designee, or at school-sponsored activities or school-sponsored athletic events. Defined: Bullying means any ongoing pattern of physical, verbal, or electronic abuse.

If you are a student victim, the parent/guardian of a student victim, a close relative of the student victim, or a school staff member and wish to report an incident of alleged bullying, harassment or intimidation, complete this form and contact the school's administration.
Email address *
Today's Date: *
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Time
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School *
Person Reporting Incident (first and last name) *
Your answer
Person Reporting Incident (telephone number) *
Your answer
Person Reporting Incident (email address) *
Your answer
Person Reporting Incident (check appropriate box) *
Required
Name, Age and School of alleged student victim(s) *
Your answer
Name, Age and School of alleged witnesses? *
Your answer
Name, Age and School of alleged offenders? *
Your answer
What date did this alleged incident happen? *
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YYYY
Where did the alleged incident happen? *
Required
Check the statement(s) that best describe what happened (choose all that apply) *
Required
Describe the incident, including what the alleged offender(s) said or did *
Your answer
Why did the bulllying, harassment or intimidation occur in your opinion? *
Your answer
Did a physical injury result from this incident? *
Did the injury require medical attention? *
Was the student victim absent from school as a result of the incident? *
Is there any other information you would like to provide? *
Your answer
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