Report on Bullying Incident
Page 1 of 1
Student Complaint Form
1.
Full Name of Person Reporting:
2.
Date of Incident:
*
(or estimate)
mm/dd/yyyy
3.
Grade Level:
--None--
K
1
2
3
4
5
6
7
8
9
10
11
12
4.
Did this incident happen to you?
*
--Please Select--
Yes
No
5.
What is your relationship to the person the incident happened to if it isn't you?
*
6.
School student attends
*
--Please Select--
Marshfield Senior High School
Marshfield Middle School
Grant Elementary
Lincoln Elementary
Madison Elementary
Nasonville Elementary
Washington Elementary
7.
Location the incident took place:
*
8.
Rude, Mean, Conflict or Bullying?
*
Please select the option that best describes the incident.
9.
Is it one-sided or two-sided?
*
10.
Did it happen more than once?
*
--Please Select--
Yes
No
11.
Do you think they did it on purpose?
*
--Please Select--
Yes
No
12.
Were they told to stop?
*
--Please Select--
Yes
No
13.
Who was involved?
*
14.
In your own words, describe exactly what happened. Include what you said and did, as well as what they said and did and when this happened.
*
15.
Witnesses: List the names of any people who may have heard or seen the incident.
*
16.
This complaint is based upon my honest belief that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge.
*
--Please Select--
Yes
No
17.
I understand that the complaint will be investigated and that, although the administration will protect the confidentiality of individuals providing information as best as possible, confidentiality of this complaint cannot be guaranteed.
*
--Please Select--
Yes
No