Incident Complaint & Bullying Report Form

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Please use this form to document alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored event or activity off school property, on a school bus, or on the way to and/or from school. Also use this form to report cyberbullying by a scholar to another UME scholar. Please be reminded that bullying and harassment can be perpetrated by an adult as well and therefore can be reported on this form.

If you are a scholar victim, the parent/guardian of a scholar victim, or a close adult relative of a scholar victim, or a school staff member and wish to report an incident of alleged bullying or cyberbullying, harassment, or intimidation, complete and submit this online form. The form will be reported to the Principal of the School, but feel free to contact the school for additional information or assistance at any time.

IMPORTANT: PLEASE BE AWARE THAT INTENTIONALLY MAKING A FALSE REPORT OR RETALIATION AGAINST ANY PERSON WHO REPORTS, IS THOUGHT TO HAVE REPORTED, FILES A COMPLAINT, OR OTHERWISE PARTICIPATES IN AND INVESTIGATION OR INQUIRY CONCERNING ALLEGATIONS OF BULLYING IS PROHIBITED AND MAY RESULT IN SCHOOL DISCIPLINE OR ACTION BEYOND THE SCOPE OF THE SCHOOL

CAMPUS OF INCIDENT *

Dallas Secondary

Dallas Elementary

Duncanville

Mansfield

DATE OF INCIDENT *

YYYY

APPROXIMATE TIME OF INCIDENT

Time

Where did this happen? *

On campus

Off Campus

On-line - cyberbullying that affects the school environment

Other:

Required

Person reporting the incident (optional)

Please select the appropriate box, are you *

Scholar (witness / bystander)

Scholar (other)

Parent / Guardian

Close adult relative

School Staff

Friend

Other:

Required

Your telephone number (optional)

Your email address (optional)

Name of alleged victim *

What school does the alleged victim attend? *

Grade of victim (if known)

Name of alleged offender (s) if known:

School role of alleged offender

Student

Staff

Other

Clear selection

Witness(es) present

Physical evidence (check all that apply) *

Graffiti

Notes

Website(s)

Text message(s)

Video/Audio

None

Other:

Required

Please identify the statement(s) that best describes what happened (choose all that apply) *

Getting another person to hit or harm the scholar

Demeaning and making the person the victim of jokes

Making rude and/or threatening or innappropriate gestures

Using racial or cultural slurs or negative comments about a person's cultural make up or background

Inappropriate touching

Excluding or rejecting the student

Intimidating (bullying), extorting or exploiting

Spreading harmful rumors or gossip

Electronic communication (such as cyberbullying)

Retaliation

Teasing, name-calling, making critical remarks in person or by other means

Stalking, taunting, coercing, menacing, or threatening in person or by other means

Other:

Required

Please state any additional concerns, descriptions, or details below (i.e., what did the alleged offender(s) say or do? How did it make you feel?) *

What is the nature of this incident? Was it about ... *

Ancestry

Creed

Disability

Mean-spirited behavior

National Origin

Physical Appearance

Race

Religion

Pregnancy, Marital, or Parental Status

Sex

Sexual Orientation

To impress others

Other:

Submit

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