Bullying report

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Bullying Report Form
You can file the report anonymously if you like. Since no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report, I strongly recommend that you do NOT report anonymously.
↓ Person filling out this report ↓

for anonymous person

NOTE: By submitting an anonymous form, there will be NO consequences for the aggressor (bully) if the investigation finds that there was bullying. It is very important to report all incidents of bullying, even if you choose to stay anonymous.

The district is responsible to make sure that any report does NOT result in retaliation. Any retaliation will be handled as additional bullying with consequences. You should strongly consider filing the report with your name on it.

When you "submit" this form, you will receive a completed bullying form that you can bring to the school. If you like, we can also automatically email the information anonymously for you. You will have that choice after filling out the other information.

for non-anonymous person

YOUR Name, the person filling out the form
The TARGET is the person being bullied. Choose "Target" if YOU are being bullied or harassed. If you are reporting about someone else being bullied or harassed, you are the "Reporter" and should choose that option.
School YOU attend
Enter your telephone number and email address so that the school can get in touch with you. Although optional, I advise you to enter both.
Enter Email
Confirm Email
↓ About the target, the person being bullied ↓
The "TARGET" is the person being bullied or harassed. It may be you, or the person who you are filling out the form for. Enter the name of the person being harassed or bullied.
What is the name of the school that the person being bullied attends?
What grade is the person being bullied in?
↓ About the aggressor ↓
What is the name of the accused bully?
What is the name of the school that the accused bully attends?
What grade is the accused bully in?
↓ About the type of incident(s) ↓
Date of the incident being reported or multiple dates for similar incidents
Where the bullying or harassment happened. One or several locations.
I believe there may be DISABILITY issues involved.
I believe there may be RACE or COLOR issues involved.
I believe there may be SEXUAL ORIENTATION issues involved.
I believe there may be GENDER DISCRIMINATION involved.
I believe there may be RELIGIOUS DISCRIMINATION involved.
I believe there may be AGE DISCRIMINATION involved.
↓ About any witnesses ↓
This report has room for up to three witnesses. If there are more, add an additional sheet of paper. If there is at least one witness to the bullying or harassment, put that person's name here.
If there is a third witness, add them here.
If there is a third witness, add them here.
↓ Specifics ↓
This is where you describe the incident or incidents. Give facts and quotes as necessary. If you need more room, you can add additional pages after printing out this form.
If there was not enough room to enter all the information, you can continue it on a separate sheet of paper or on the back of the form after you print it. Check this box to let the school know that the description is continued.
Do you have other documentation that you believe will be helpful to the school but it is not on this form. It might be pictures, videos, screen shots, emails, etc. If you pick "Attached," you will attached those materials to the form you print out.
Drop a file here or click to upload Choose File
Maximum upload size: 2.1MB
↓ We can send the form ↓

We can send the bullying form attached to an email for you. If you chose to be anonymous (at the top of this form), the email will come from this computer server and there will be no connection to you in the email at all. If you entered your name and email address on the form, the email will contain your information and you will receive a copy as well.

The form will be downloaded to you automatically when you hit SUBMIT. It is strongly suggested that you send the form to the school Principal and the district Superintendent. If you enter their addresses, we will send it for you.

Enter Email
Enter Email
↓ Almost done ... ↓

sig section if not annonymous

By filling in my name below and checking the box, I acknowledge that I have read and understood the provisions above and certify that the information I have provided is true and correct to the best of my knowledge, and I adopt this as my online signature.
↓ Done! ↓

By clicking on the "Submit" button, the data will be merged onto the proper form so you can give it to the school district. You can download the form after you hit the Submit button. Once downloaded, you can open the report in Adobe Reader (or your browser) to edit, view, or print.

The form will be created and you will be able to download it. If you have entered your email address above, you will also get a copy of the form emailed to you. What else should happen?

If you need help after submitting, Contact me.

If you need Adobe Acrobat Reader DC (the odds are you don't), download here.