Report a Bullying Incident

Report a Bullying Incident

Report a Bullying Incident

I am a: 

 

Name (Optional, but helpfull:  

 

Address (Optional) 

 

E-Mail Address (Optional)  

 

Daytime Phone (Optional)  

 

Student Victim Name:  

 

Victim's School:   

 

Victim's Grade    

 

Alleged Offenders Name and Grade (If known; If more than one, include all names seperated by commas):

 

Date and Time of incident (If known; specify AM or PM)  

 

Has this incident been reported to anyone yet?  If so, to whom (teacher, parent, etc,):

 

Were there any witnesses?: 

 

Please provide names of witnesses (if known): 

 

Did you witness the bullying firsthand?:

 

Describe what happened and how long it has occurred:

 

Additional Information (Optional)

 

Law Enforcement should be contacted if you are aware of:

Death threats or threats of other forms of violence to a person or property

Excessive intimidation or extortion

Threats of intimidation that involve any form of bias or discrimination

Any evidence of sexual exploitation or abuse

 

 



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