*  *  Bullying Prevention and Intervention Incident Reporting Form  *  *

Complete the form below and click on the "Submit Form" button to submit directly and anonymously to the Superintendent of Schools.

 

  1. Reports may be made anonymously, but no disciplinary action will be taken against an alleged aggressor solely on the basis of an anonymous report.

    If you choose to provide your name, please enter here:


     

  2. Check whether you are the:           Target of the behavior:             Reporter (not the target) 


     

  3. Check whether you are a:            Student          Staff Member          Parent            Other


     

  4. Information about the Incident:


    Name of Target(s) (of behavior): 

    Name of Aggressor(s) (Person engaged in the behavior): 

    Date(s) of Incident(s): 

    Time When Incident(s) Occurred: 

    Location of Incident(s) (Be as specific as possible): 



     

  5. Witnesses (List people who saw the incident or have information about it):

       Name:      


       Name:      


       Name:      




     

  6. Describe the details of the incident (including names of people involved, what occurred, and what each person did and said, including specific words used.