Harassment, Intimidation, or Bullying Reporting Form

Your First and Last Name*

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Targeted Student's Name*

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Your email address (optional)

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Your phone number (optional)

Number Required

School/Location of incident:*

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Name of school adult you've already contacted (if any):

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Name(s) of bullies (if known):

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Describe the incident(s) in detail. Provide as much information as possible to help us understand the situation.*

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On what dates did the incident(s) happen (if known):

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Why do you think the harassment, intimidation or bullying occurred?*

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If yes, please provide names of witnesses:

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Did a physical injury result from this incident? If yes, please describe.

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Was the target absent from school as a result of the incident? If yes, please describe.

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How often have incident(s) occurred?*

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One time

On multiple occasions

Other:

Is there any additional information?

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Please fix the highlighted areas below before submitting.