BULLYING/HARASSMENT REPORT FORM

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PLEASE USE THIS FORM TO REPORT ANY BULLYING OR HARASSMENT THAT YOU EXPERIENCE OR WITNESS. YOUR NAME AND CONTACT INFORMATION IS REQUIRED SO THE COUNSELOR AND/OR AN ADMINISTRATOR CAN OBTAIN FURTHER INFORMATION FROM YOU AND FOLLOW-UP AS NEEDED. THE INFORMATION YOU PROVIDE WILL BE CONFIDENTIAL.

Email *

Your Name (FIRST NAME, LAST NAME) *

Name of the student that is bullying and/or harassing: *

Provide a brief description of the situation: *

Please list the first and last names of any students that may have witnessed this incident:

What is the best phone number to reach you? *

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