Bullying/ Harassment Form

ANY FALSE REPORTS WILL RESULT IN DISCIPLINARY ACTION EITHER BY THE SCHOOL AND/OR POSSIBLY THE SCHOOL RESOURCE OFFICER.

Press the tab key to advance the form.

Please provide the following contact information:

Student filing complaint:

Grade:

Homeroom Teacher:

Who has bullied you:

What grade is this person in

What date did this incident take place:

What time did this incident take place:

How long has this been going on with you and this person:

Check all that this person has done to you: Kicked
Shoved
Hit you
Threatened verbally
Called on phone
Internet messages
Written threats
Drew threatening pictures
Teased you

Witnesses to this incident:

Witnesses to other incidents:

Where does it occur:

What time of the day (class period, in between classes, etc.):

Who have you told about this incident:

What do you think should happen as a result of this or other incidents:

What have you done to try to get this person to stop bullying/harassing you?

Is there anything else you would like to add to this report?

Student filing complaint:
Grade:
Homeroom Teacher:
Who has bullied you:
What grade is this person in
What date did this incident take place:
What time did this incident take place:
How long has this been going on with you and this person:
Check all that this person has done to you:	Kicked Shoved Hit you Threatened verbally Called on phone Internet messages Written threats Drew threatening pictures Teased you
Witnesses to this incident:
Witnesses to other incidents:
Where does it occur:
What time of the day (class period, in between classes, etc.):
Who have you told about this incident:
What do you think should happen as a result of this or other incidents:
What have you done to try to get this person to stop bullying/harassing you?
Is there anything else you would like to add to this report?