Bullying Complaint Report Form

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This form is to report concerns of bullying to the school administration. Parents or students may use this form to report allegations of bullying. Per the policy, bullying is defined as:
- Unwanted aggressive behavior,
- Involves a real OR perceived imbalance of power, AND
- Is repeated or has the potential to be repeated overtime.
All three parts of this definition must be present in a situation to be considered bullying. Please understand that not all negative peer conflict is actually bullying.

Email *

Name of Student: *

Grade: *

Today's Date: *

YYYY

Names of Accused: *

Address:

Date of Incident:

YYYY

Telephone Number: *

Specify in detail your complaint below. Please describe the incident, participants, background to the incident, and any attempt you've made to resolve the problem. Please include relevant dates, times, and places. *

Indicate if there are other individuals who could provide more information regarding this complaint including witnesses or participants.

Indicate in your opinion how this problem might be resolved. Please be as specific as possible. *

Name of Complainant (whomever is filling out this form) *

I certify that the above information is correct and that the events are accurately depicted to the best of my knowledge *

Yes

A copy of your responses will be emailed to the address you provided.

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