Pupil Services

Bullying, Harassment or Intimidation Form

Directions:  Bullying, harassment, or intimidation are serious and will not be tolerated.  This is a form to report alleged bullying, harassment, or intimidation that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school*, in the current school year.  If you are a student victim, the parent/guardian of a student victim, or a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying harassment, or intimidation, complete this form and return it to the Principal at the student victim’s school.  Contact the school for additional information or assistance at any time.

School Information
Person Reporting Incident:
1. Victim Information
First Victim
Second Victim
Third Victim
2. Alleged Witness(es) (if known)
First Alleged Witness (if known)
Second Alleged Witness (if known and relevant)
Third Alleged Witness (if known and relevant)
3. Alleged Offender(s) Information (if known)
First Alleged Offender (if known)
Second Alleged Offender (if known and relevant)
Third Alleged Offender (if known and relevant)
4. On what date(s) did the incident happen?
5. Check the statement(s) that best describes what happened (choose all that apply):
6. Where did the incident happen (choose all that apply)?
7. Describe the incident(s), including what the alleged offender(s) said or did:
8. Why did the bullying, harassment or intimidation occur?
9. Did a physical injury result from this incident?
10. If there was a physical injury, do you think there will be permanent effects?
11. Was the student victim absent from school as a result of the incident?
12. Did a psychological injury result from this incident?
13. Is there any additional information you would like to provide?
Your Signature
* Will be collected unless specifically excluded by local board policy
NOTE: To prevent fraud, you must submit this form by 2:00 pm.