Report on Bullying Incident

Your full namePlease enter your legal name

First Name

Last Name

Please enter your legal name

Date of Incident (or estimate):required

Enter the day or approximate day the incident took place (Must contain a date in M/D/YYYY format)

Grade Level

Select from the dropdown menu

Did this incident happen to you?required

Yes

No

Name of Person the Incident happened torequired

First Name

Last Name

Other, please specify

School student attendsrequired

The student of which the incident happened to

Rude, Mean, Conflict or Bullying?requiredPlease select the option that best describes the incident.

RUDE: disrespectful, impolite or inappropriate behavior others do not like

MEAN: unplanned, saying or doing something disrespectful on purpose that hurts the other person’s feelings

CONFLICT: two-sided disagreement, both people are being disrespectful, there is equal power and they are equally upset

BULLYING: when someone is mean on purpose, is one-sided and typically happens more than once. There is an imbalance of power and one person is being mean on purpose while the other person is staying respectful.

Please select the option that best describes the incident.

Is it one-sided or two-sided?required

One-sided

Two-sided

I don't know

Did it happen more than once?required

Yes

No

I don't know

Do you think they did it on purpose?required

Yes

No

I don't know

Were they told to stop?required

Yes

No

I don't know

Who was involved?required

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.required

Witnesses: List the names of any people who may have heard or seen the incident.required

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.required

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.required

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Report on Bullying Incident

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