Bullying and Harassment Report Form

If this is an emergency that needs immediate attention please call 911 or contact your health care provider immediately as this site is only monitored during school hours.

Please be advised, if a report is made anonymously it will limit our investigation process and we will be unable to follow up with the person making the report.

Students found responsible for deliberately making false reports may be subject to a full range of disciplinary consequences as publicized in student handbooks.

Name of Reporter/Person Filing the Report

Optional: If a report is made anonymously it will limit our investigation process and we will be unable to follow up with the person making the report.

Email of person reporting

Optional

Are you the target of the behavior?

Yes
No

Are you a:

Student
Staff Member
Parent

Your School/Building

Information about the Incident

Name of target (of behavior)*

First Last

Name of Aggressor (person who engaged in the behavior)*

First Last

Date of Incident*

Time of Incident*

: Hour

Minute

Location of Incident*

Witnesses

List people who saw the incident or have information about it.

Witness One

Witness Two

Witness Three

Incident Details

Detail of Events*

Describe the detail of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used).

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Information about the Incident

Witnesses

Incident Details

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