Bullying Incident Report Form
If you (or your student), has been the target of bullying or have witnessed the bullying of a District student, completed this form and submit. 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.

Principal, Assistant Principal and the School Counselor will be notified as soon as the form is submitted. 

Reports of bullying or harassment will be investigated, parents will be notified and disciplinary action will be taken as warranted.

Anyone can make a report. Contact the school for additional information or assistance if need be.
Sign in to Google to save your progress. Learn more
Person reporting Incident:
Name:
Phone Number
Select from the choices below to best describe yourself:
Has this incident been reported to anyone else? *
Victims (or persons being bullied) information:
Date of Incident: *
MM
/
DD
/
YYYY
Name(s) of Victim(s):  *
Grade Level
Alleged Bully information
Name of first alleged Bully *
Is the first alleged Bully a district student? *
Name of second alleged Bully 
Is the second alleged Bully a district student?
Clear selection
Name of third alleged Bully
Is the third alleged Bully a district student?
Clear selection
Where did the incident happen (Select all that apply)? *
Required
What happened (choose all that apply?) *
Required
What did the alleged Bully(ies) say or do? *
Is there any additional information you would like to provide?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Montgomery County R-II School District. Report Abuse
Google Forms