STOP BULLYING Report Form
Please complete the form. You must include your name (which will be confidential) at the bottom of the form. Please note that the district’s ability to investigate an anonymous complaint may be limited, and the law prohibits retaliation against anyone who files a bullying report.
Your Name (This will be kept confidential)? *
Your grade? *
Your age? *
School *
Type of Bullying *
Describe what happened/what is happening:
When did it happen? *
Date of incident *
MM
/
DD
/
YYYY
Time of Incident *
Time
:
Where did it happen? *
Who was committing the bullying (if you don't know the bully's name (s) describe him/her? *
Who was the target of the bullying (if you don't know the bully's name (s) describe him/her? *
Did anyone else witness the bullying (if yes, please list)? *
If yes, please list.
Were you or others physically hurt (please explain)? *
If yes, please list.
Was there damage to anyone's property? *
If yes, please list.
Have you told anyone about the bullying? *
Have you previously reported a bullying incident regarding this same individual (s)? This information will be used to determine if retaliation is occurring. *
How can we contact you? *
If by Phone, please enter number.
If by email, please enter email address.
TO BE COMPLETED BY SCCSD STAFF ONLY
Resulting action executed, planned or recommended (Attach response if needed):
Markricus Hibbler, Chief of Security
Phone: (662) 207-4720
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