Center School Bullying Report Form
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Reporters Name
You can leave this blank and remain anonymous, but no disciplinary actions can be enacted based solely on an anonymous report.
Type of Reporter
You can leave this blank and remain anonymous, but no disciplinary actions can be enacted based solely on an anonymous report.
Clear selection
Contact Information
Please leave a phone number we can reach you at.
Type of Incident
Bullying is:
  • A repeated action by one or more students or staff
  • A written, verbal or electronic expression or a physical act or gesture or any combination thereof
  • Directed at a target (victim)
Harassment is conduct in any form (verbal, written, electronic, physical) that is:
  • Unwelcome
  • On school grounds or in any school-related event or activity (or out-of-school conduct if it creates a hostile environment)
  • Relating to a student’s status as a member of a protected class
  • Sufficiently severe, persistent or pervasive
  • Creates a hostile, harmful or humiliating environment at school
Select all that apply, use "Other" if needed.
Incident time
When did the incident happen, check all that apply.
Incident Location
Where did the incident happen, check all that apply.
Please describe the incident *
Online Evidence
Please save and gather any screenshots regarding the incident.
Submit
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This form was created inside of Old Rochester Regional School District. Report Abuse