Bullying report If you Register and Log In to the site, you can keep drafts and continue to work on your bullying report later. Bullying Report Form If you are human, leave this field blank. 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. want to be anonymous I want to stay Anonymous ↓ 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 Name: 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. Are you the TARGET of the bullying or just reporting it? Target Reporter Are YOU a: Parent Student Staff member Administrator Other What school do you attend? School YOU attend What grade are you in? What is your role with the district? What is your title? Please explain: 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. YOUR telephone number: YOUR email address: Enter Email Confirm YOUR email address: 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. Name of the TARGET: Target's school: What is the name of the school that the person being bullied attends? Target's grade: What grade is the person being bullied in? ↓ About the aggressor ↓ What is the name of the accused bully? Name of AGGRESSOR: Aggressor's school: What is the name of the school that the accused bully attends? Aggressor's grade: 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 Date (or dates) of incident(s): Where the bullying or harassment happened. One or several locations. Location of incident(s): Time of incident(s) Making fun of someone's "disability" by teasing them about it, calling them "stupid" or "retarded" or "lame" should be noted. I believe there may be DISABILITY issues involved. Disability Speaking of their race or color, using negative words about them should be noted. I believe there may be RACE or COLOR issues involved. Race/Color Teasing or bullying and using words like "fag," "dyke," "you do that like a girl," "gay," or in any way referencing sexual orientation is a civil rights issue. I believe there may be SEXUAL ORIENTATION issues involved. Sexual Orientation Harassment or bullying because of someone's gender is illegal. I believe there may be GENDER DISCRIMINATION involved. Gender Discrimination Making fun of someone's religion, religious practices or customs, religious clothing or jewelry is also a civil rights issue. I believe there may be RELIGIOUS DISCRIMINATION involved. Religion Harassment or bullying someone because of their age is also a civil rights issue. I believe there may be AGE DISCRIMINATION involved. Age ↓ 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. Name of a witness: What is that witness? Student Staff Other Describe "other" Is there a second witness? Yes No Name of second witness: What is the second witness? Student Staff Other Describe "other" Is there a third witness? Yes No If there is a third witness, add them here. Name of third witness: If there is a third witness, add them here. What is the thrid witness? Student Staff Other Describe "other" ↓ 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. Description of incident: * 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. Is the description continued on another page? Yes, there will be more written 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. Is there more documentation? No Attached Yes, but not attached File Upload Uploading Files. Please Wait. Drop a file here or click to upload Choose File Maximum upload size: 3MB ↓ 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. Principal's Email Address Enter Email Superintendent's Email Address Enter Email ↓ Almost done ... ↓ Did you read the Privacy Policy? * I have read, and agree to, the Privacy Policy! 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. E-Signature Checkboxes I agree with the Signature declaration reCAPTCHA ↓ 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? In addition to creating the form, please: Do nothing else, I will print the form and deliver it. Email the form to the school district email addresses as specified above. SUBMIT If you need help after submitting, Contact me. If you need Adobe Acrobat Reader DC (the odds are you don't), download here.
