Parent Reporting Bullying/Harassment Form

This form is a confidential form for reporting bullying and harrassment. Please see student handbook for more detailed informationabout school followup procedures.

Please complete all fields. Required fields are marked with an asterisk.*

Email Address*

Answer required for "Email Address"

Which of the following are you reporting?*

Answer required for "Which of the following are you reporting?"

Intimidation

Unwanted Agressive Behavior

Cyberbullying

Other:

If other, please explain:

Answer required for "If other, please explain:"

Does any student that you are aware of fear for their physical safety?*

Answer required for "Does any student that you are aware of fear for their physical safety?"

Yes

Not Sure

Which of the following apply to what you are reporting?*

Answer required for "Which of the following apply to what you are reporting?"

It keeps happening

It has negatively affected student school work

It is disruptive to the school operation

None of the above

Which of the following apply to you?*

Answer required for "Which of the following apply to you?"

I saw it happen

My child told me it happened

Another student told me it happened

I overheard students talking about it

Another parent told me it happened

Briefly describe what happened.*

Answer required for "Briefly describe what happened."

Select any actions that have occurred between these students during this incident or in the past.

Answer required for "Select any actions that have occurred between these students during this incident or in the past."

Exclusion

Teasing

Name Calling

Making fun of

Pushing or stepping in front of

Cyberbullying

If you know the names of other students involved or witnesses, please include their names here.

Answer required for "If you know the names of other students involved or witnesses, please include their names here."

Please provide your contact information here including phone number and email address

Answer required for "Please provide your contact information here including phone number and email address"

Please fix the highlighted areas below before submitting.

Parent Reporting Bullying/Harassment Form