Report Bullying

Name

First

Last

Address

Phone Number

Email

I am: (choose as appropriate)

• Student
• Parent/Guardian of Student
• Employee
• Other

Basis for allegation: (check all which apply)

• Race
• Color
• Age
• Religion/Creed
• Sex/Gender
• Sexual Orientation
• Ancestry National Origin
• Disability/Handicap
• Family Status
• Other

Name(s) of person(s) you believe violated the school's bullying policy

If the alleged bullying was directed against another person(s), identify the other person(s)

When and where the incident occurred

List any witnesses who were present

Describe the incident as clearly as possible, including any verbal threats, remarks, comments, etc., and any actions or activities. Attach additional pages if necessary

Name

Submit