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Bullying, Harassment, or Intimidation Reporting Form

Directions: Bullying, harassment, or intimidation is serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored activity or event off of school property, on a school bus, or on the way to and/or from school in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, or a school staff member, and wish to report an incident of alleged bullying, harassment or intimidation, please complete this form.  Once complete, the results of this form will automatically be sent to the principal at the student victim’s school.

The results of this form will be monitored between the hours of 7:00am - 5:00pm during the school year.  Any reports submitted outside of these hours, or during holidays, will be investigated during the following normally scheduled school day.  Please do not use this system for issues requiring immediate assistance.  If this is an emergency requiring immediate assistance, please call 911.  Contact the school directly for additional information or assistance during posted office hours.

Bullying, harassment, or intimidation is defined as intentional conduct that can be verbal, physical, face-to-face, and/or electronic or written communication and which creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, performance, or with a student’s physical or psychological well-being and is:

  • motivated by an actual or a perceived personal characteristic - including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability or disability, or
  • threatening or seriously intimidating, and
  • occurs on school property, at a school activity or event, on a school bus, or
  • substantially disrupts the orderly operation of a school.
The information provided on this form is considered, and will be kept, confidential.
1 Start 2 Victim(s) 3 Witnesses 4 Offender(s) 5 Incident 6 Injury 7 Additional Info 8 Preview 9 Complete
(Hidden)This will auto-fill if you arrived from a school website.
Please select the school site where the incident occurred. (Auto-selected if arriving from school website.)
This field will auto-fill based on school selection.
(HIDDEN) This field will auto-fill based on school selection.
(HIDDEN) This field will auto-fill based on school selection.
Person Reporting Incident
Enter the name of the person reporting the incident. (Smith, John)
Enter the telephone number for the person reporting.
Please check the most appropriate box.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
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