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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 is any intentional and repeated act of unwanted aggressive or demeaning behavior involving a real or perceived power imbalance that takes place on or off school property, in which one or more people intentionally and repeatedly cause physical or psychological harm to another person. To be considered bullying, the conduct must also place a student in reasonable fear of harm or of damage to property, have the effect of substantially interfering with educational performance or school operation, or create a hostile, intimidating, threatening, or abusive educational environment.
The information provided on this form is considered, and will be kept, confidential.
59 Questions
The incident(s) you are reporting involve a real or perceived power imbalance (answer must be "yes" to proceed). Reminder: Bullying is any intentional and repeated act of unwanted aggressive or demeaning behavior involving a real or perceived power imbalance that takes place on or off school property, in which one or more people intentionally and repeatedly cause physical or psychological harm to another person.
The incident(s) you are reporting involve *repeated* physical or psychological harm (answer must be "yes" to proceed"). Reminder: Bullying is any intentional and repeated act of unwanted aggressive or demeaning behavior involving a real or perceived power imbalance that takes place on or off school property, in which one or more people intentionally and repeatedly cause physical or psychological harm to another person.
School where incident occurred.
Enter the name of the person reporting the incident. (Smith, John)
Please enter the email address for the person reporting.
Please select the most appropriate option.
Please enter the name of the alleged first student victim. (Smith, John)
Please select the school this alleged victim attends.
Please select this alleged victim's grade level.
Please enter the name of the alleged second student victim. (Smith, John)
Please select the school this alleged victim attends.
Please select this alleged victim's grade level.
Please enter the name of the alleged third student victim. (Smith, John)
Please select the school this alleged victim attends.
Please select this alleged victim's grade level.
Please enter the name of the alleged first alleged witness. (Smith, John)
Please select the school this alleged witness attends, if applicable.
Please select the most appropriate option.
Please enter the name of the alleged second alleged witness. (Smith, John)
Please select the school this alleged witness attends, if applicable.
Please select the most appropriate option.
Please enter the name of the alleged third alleged witness. (Smith, John)
Please select the school this alleged witness attends, if applicable.
Please select the most appropriate option.
(Smith, John) Enter "Unknown" if not known.
Enter age if known.
Please select the school this alleged offender attends, if applicable.
Please select the most appropriate option.
(Smith, John) Enter "Unknown" if not known.
Enter age if known.
Please select the school this alleged offender attends, if applicable.
Please select the most appropriate option.
(Smith, John) Enter "Unknown" if not known.
Enter age if known.
Please select the school this alleged offender attends, if applicable.
Please select the most appropriate option.
Check all that apply.
Check all that apply.
Why did the bullying, harassment, or intimidation occur? (Check all that apply.)
(If known)
Did a physical injury result from this incident?
If a physical injury was selected above, do you think there will be permanent effects? (Select NO if there was no physical injury.)
Did a psychological injury result from this incident?
Has the student made or reported any threat of suicide, or suicidal thoughts?
Was the student victim absent from school as a result of the incident?
How many days was the student victim absent from school as a result of the incident? Enter 0 if the student did not miss any days.
Please list any additional details regarding the injury.
Is there any additional information you would like to provide?