Incident Complaint & Bullying Report Form
Please use this form to document alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored event or activity off school property, on a school bus, or on the way to and/or from school. Also use this form to report cyberbullying by a scholar to another UME scholar. Please be reminded that bullying and harassment can be perpetrated by an adult as well and therefore can be reported on this form.
If you are a scholar victim, the parent/guardian of a scholar victim, or a close adult relative of a scholar victim, or a school staff member and wish to report an incident of alleged bullying or cyberbullying, harassment, or intimidation, complete and submit this online form. The form will be reported to the Principal of the School, but feel free to contact the school for additional information or assistance at any time.
IMPORTANT: PLEASE BE AWARE THAT INTENTIONALLY MAKING A FALSE REPORT OR RETALIATION AGAINST ANY PERSON WHO REPORTS, IS THOUGHT TO HAVE REPORTED, FILES A COMPLAINT, OR OTHERWISE PARTICIPATES IN AND INVESTIGATION OR INQUIRY CONCERNING ALLEGATIONS OF BULLYING IS PROHIBITED AND MAY RESULT IN SCHOOL DISCIPLINE OR ACTION BEYOND THE SCOPE OF THE SCHOOL
DATE OF INCIDENT
APPROXIMATE TIME OF INCIDENT
Where did this happen?
On-line - cyberbullying that affects the school environment
Person reporting the incident (optional)
Telephone number (optional)
Email address (optional)
Please select the appropriate box, are you
Scholar (witness / bystander)
Parent / Guardian
Close adult relative
Name of alleged victim
Grade / Age
Name of alleged offender (s) if known:
Physical evidence (check all that apply)
Please identify the statement(s) that best describes what happened (choose all that apply)
Getting another person to hit or harm the scholar
Demeaning and making the person the victim of jokes
Making rude and/or threatening or innappropriate gestures
Using racial or cultural slurs or negative comments about a person's cultural make up or background
Excluding or rejecting the student
Intimidating (bullying), extorting or exploiting
Spreading harmful rumors or gossip
Electronic communication (such as cyberbullying)
Teasing, name-calling, making critical remarks in person or by other means
Stalking, taunting, coercing, menacing, or threatening in person or by other means
Please state any additional concerns, descriptions, or details below (i.e., what did the alleged offender(s) say or do? How did it make you feel?)
What is the nature of this incident? Was it about ...
Pregnancy, Marital, or Parental Status
To impress others
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This form was created inside of UME Preparatory Academy.