Reporting Form for Allegations of Bullying or Retaliation Related to Bullying

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Reports may be made anonymously (unless reporter is a staff member or administrator). No disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous complaint.

School *

Name of Person Filing the Report or if Anonymous, Enter "Anonymous".

Reports may be made anonymously unless reporter is a staff member or administrator

Are you the target of the behavior or a reporter?
*

Target

Reporter (Not the Target)

Are you a student, staff member, parent or administrator?
*

Student

Parent

Staff Member (please indicate your role on the line below)

Administrator (please indicate your role on the line below)

Other:

If you are a staff member or administrator, please specify your role below.

Please provide your contact information/telephone number.

(Not required for anonymous targets or reporters.)

Information about the alleged incident.

Name of the Alleged Target (of behavior):

Name of the Alleged Aggressor:

Person who allegedly engaged in the behavior.

Date of Incident(s):
*

YYYY

Time When Incident(s) Occurred:
*

Time

Location of Incident(s):
*

Please list names of people who saw the incident or have information about it:
*

Describe the details of the incident.

Include the name of people involved, what occurred, and what each person did and said, including specific words used, if possible.

Electronic Signature

(Note: Reports can be made anonymously unless reporter is a staff member or administrator)

Date of Signature
*

YYYY

Initial Determination Regarding Potential Civil Rights Violation: If there is evidence indicating that the reported incident is related to a race, color, religion, national origin, age, sex, gender identity, sexual orientation, disability or other protected classification, the person receiving this report must arrange for the allegations to be processed under the district's harassment policy rather than bullying policy.

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