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