Bullying Incident Report Form
If you have been the target of bullying or have witnessed the bullying of a District student, complete this form, which will be submitted to the building principal. Complaints against building principals should be submitted to the Superintendent.  Complaints against the Superintendent should be submitted to the Board of Education.  Reports of bullying will be investigated and disciplinary action will be taken as warranted.

Bullying frequently involves repeated behavior. If you have witnessed or have knowledge of more than one incident, please provide information on all incidents. Please feel free to complete multiple forms if necessary to report all related incidents.
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Email *
Name of reporter, person filing the report (If you prefer to remain anonymous, leave this blank. The district will investigate all allegation of bullying, but it is more difficult to follow up on anonymous reports.)
Date Filed
MM
/
DD
/
YYYY
Address, Phone Number, & Email (If you prefer to remain anonymous, leave this blank. The district will investigate all allegation of bullying, but it is more difficult to follow up on anonymous reports.)
Relationship to the student being bullied (parent/guardian, fellow student, community member, etc.)
Did you witness this incident?
Clear selection
If no, provide the specific information as to how you found out about this incident.
Details of the Incident
Date and time the incident took place? If the exact date and time are uncertain, provide approximate date and time.
Where did the incident take place? Be as specific as possible. For example, instead of "the middle school," specify "the sixth grade hallway girls bathroom at the middle school."
Name of Targeted Student, Grade Level (List all students that were the target of bullying. Provide as much information as you can.)
Name of Student Engaged in Bullying, Grade Level (List all students that were the target of bullying. Provide as much information as you can.)
List the names of others who witnessed or may have witnessed the incident.
Please describe the incident. Include as much detail as possible. Do not "clean up" anything that was said or done. If inappropriate language or gestures were used, include the exact language and describe the exact gesture used.
Is there any other information you believe is relevant for the district to know when investigating this incident?
*Students have the right to complete this form anonymously. However, it will be easier for the District to investigate this matter if as much information as possible is provided. Submission of a good faith complaint or report of bullying or harassment will not affect the complainant or reporter's future employment, grades, learning, or working environment. A complainant that falsely accuses someone will be subject to disciplinary action. If you wish to give your name, please leave it below. If you wish to file an anonymous report, please sign "anonymous" below.
Follow Up
This report should be accompanied by any applicable evidence that bullying occurred, such as copies of notes, emails, or photos.  If the bullying includes sexting, nudity, or inappropriate images of a minor, please do NOT copy, download, or further distribute the images!  Instead, show the evidence to the principal immediately so that appropriate actions can be taken.

Once received, this form will be forwarded to the appropriate staff member for further action.  If you have been the target of bullying or have witnessed the bullying of a District student, complete this form, which will be submitted to the building principal. Complaints against building principals should be submitted to the Superintendent.  Complaints against the Superintendent should be submitted to the Board of Education.  Reports of bullying will be investigated and disciplinary action will be taken as warranted.  Contact information for administrators is listed below.

Natalie Gibson, Ralls County Elementary, 21700 Highway 19, Center, MO 63436, ngibson@rallsr2.k12.mo.us, 573-267-3341
Carey Scherder, Ralls County Elementary, 21700 Highway 19, Center MO 63436, cscherder@rallsr2.k12.mo.us, 573-267-3341
Jennifer Hays, Mark Twain Junior High, 21622 Highway 19, Center, MO 63436, jhays@rallsr2.k12.mo.us, 573-267-3397
Deacon Windsor, Mark Twain High School, 21622 Highway 19, Center, MO 63436, dwindsor@rallsr2.k12.mo.us, 573-267-3397
Tara Lewis, Superintendent, 21622 Highway 19, Center, MO 63436, tlewis@rallsr2.k12.mo.us, 573-267-3397
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