Report Type Please select one Bullying Incident Suggestions Other Violations

Name:
(May be filled out as anonymous)

Date of Incident:

Time of Incident:

Location of Incident:

Please check the type of incident experienced:

Hitting, kicking, shoving, spitting, hair pulling, or throwing something
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in
person or by other means
Demeaning and making the victim of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating (bullying), extorting, or exploiting
Spreading harmful rumors or gossip
Electronic communications (specify)

Please describe the incident or make suggestion in the text box below.

Witnesses? Yes No

Who?

Was a teacher informed of incident? Yes No

Who?

By clicking here, I hereby certify that the information I have provided in this complaint is true, correct and complete, to the best of my knowledge and belief.