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Bullying, Intimidation & Harassment Reporting Form

To report an incident of harassment, intimidation and bullying complete this online form with as much detail as possible ad submit it electronically.

Your information will not be shared with anyone other than those involved with helping you and investigating your issue. The more you tell us, the more we can help you. IF YOU CHOOSE TO REMAIN ANONYMOUS, WE MAY NOT HAVE ENOUGH INFORMATION TO PROPERLY ADDRESS YOUR SITUATION OR RESOLVE YOUR ISSUE.

Any person who knowingly and willingly makes a false or misleading report or counsels another to make a false or misleading report may be subject to criminal and/ or civil liability.

Please complete the form below. Required fields marked with an asterisk *

Today's Date*

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PERSON REPORTING INCIDENT:

First Name (To remain anonymous, please type anonymous in this field)*

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Last Name (To remain anonymous, please type anonymous in this field)*

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Phone Number

Number Required

Email Address

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What is your relationship to the alleged victim(s)

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TARGET STUDENT(S) INFORMATION:

First name of the main student targeted (if there are other targets, please indicate that in the ADDITIONAL TARGETED STUDENTS field below)*

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Last name of the main student targeted (if there are other targets, please indicate that in the ADDITIONAL TARGETED STUDENTS field below)*

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Name(s) of any additional targeted students

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ALLEGED AGGRESSOR(S) INFORMATION

First name of the alleged aggressor*

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Last name of the alleged aggressor*

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Name(s) of any additional aggressor(s)

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INCIDENT(S) INFORMATION

Date of most recent incident*

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Has a similar incident happened before? If so, how many times?*

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Location(s) of the alleged incident(s) *

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People you have already spoken with about the incident(s)/problem (if you have not spoken with anyone prior to filling out this form, please write none)*

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Name(s) of any staff, student or other witnesses to the alleged incident(s)

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Please describe the suspected incident(s) in as much detail as possible. The more specific details you can provide, the better able we will be to address your concerns.*

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Check all that apply

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Physical violence or attacks

Threats, taunts and intimidation through words and/or gestures

Extortion, damage or stealing of money and/or possessions

Exclusion from activities, peer groups

Spreading rumors

Cyberbullying

Other:

Upload any photos, video or files related to the incident(s)

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Choose a file or drag it here.