Autauga County Schools' Student Bullying Complaint Form
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Student's (Victim) Name *
Incident Date *
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DD
/
YYYY
School Name *
Student's (Victim) Grade Level
Age
Person Reporting *
Relationship to Student (Victim), if applicable
Please check all that apply: *
Required
Specific Description of Bullying Complaint *
Please give as much description as possible
Name(s) of alleged bully(ies) *
Student is having suicidal thoughts? *
If checked, the person receiving this notification must respond to this report as a suicidal threat and the district's suicide / homicide protocols must be followed.
Required
The Autauga County Board of Education prohibits all forms of bullying against students. The Board’s Anti-bullying policy can be found in the Student Code of Conduct Manual. The Jamari Terrell Williams Student Bullying Prevention Act, No. 2018-472, defines bullying as a continuous pattern of intentional behavior that takes place on school property, on a school bus, or at a school-sponsored function including, but not limited to, cyberbullying or written, electronic, verbal, or physical acts that are reasonably perceived as being motivated by any characteristic of a student, or by the association of a student with an individual who has a particular characteristic, if the characteristic falls into one of the categories of personal characteristics contained in the policy adopted by the local board.
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