Bullying/Harassment Incident Form

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Reporting a bullying or harassment incident will result in an investigation procedure outlined in the district's handbook.

Your Email: *

Your Name:

(In order for a complaint to be fully investigated, your name is required.)

Are you filing this form for yourself or for someone else? Please identify that individual. *

Who or what entity do you believe discriminated against, harassed, or bullied you (or someone else)? *

Date and place of alleged incident(s): *

Name(s) of witnesses: *

Nature of discrimination, harassment, or bullying alleged (check all that apply): *

Age

Disability

Familial Status

Gender Identity

Marital Status

National Origin/Ethnic Background/Ancestry

Physical Attribute

Physical/Mental Ability

Political Belief

Political Party Preference

Race/Color

Religion/Creed

Sex

Sexual Orientation

Socio-economic Background

Other:

Required

Describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible. *

Describe evidence that you have of the alleged discrimination, harassment, or bullying. If you have any physical evidence (such as letters, photos, emails, text messages, etc.), bring the evidence to the principal or dean's office. Do not delete emails or texts. *

Any other information:

By submitting this form, you are agreeing that this information is accurate and true to the best of your knowledge. *

I agree this is accurate and true.

I do NOT agree this is accurate and true.

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