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 *
MM
/
DD
/
YYYY
APPROXIMATE TIME OF INCIDENT
Time
:
Where did this happen? *
Required
Person reporting the incident (optional)
Your answer
Telephone number (optional)
Your answer
Email address (optional)
Your answer
Please select the appropriate box, are you *
Required
Name of alleged victim *
Your answer
Grade / Age
Your answer
Name of alleged offender (s) if known:
Your answer
Witness(es) present
Your answer
Physical evidence (check all that apply) *
Required
Please identify the statement(s) that best describes what happened (choose all that apply) *
Required
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?) *
Your answer
What is the nature of this incident? Was it about ... *
Submit
Never submit passwords through Google Forms.
This form was created inside of UME Preparatory Academy. Report Abuse