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



Security Measure