Bullying and Cyberbullying Reporting Form

Bullying or suspected bullying is reportable in person or in writing (including anonymously) to school personnel. 
Upon completion of this form, or when providing a verbal report, submit to designated school personnel or administrative office.

Date the alleged incident of bullying is being reported: _______________________

Person(s) reporting the alleged incident(s) of bullying (this is optional as reports can be made anonymously, except when reported by staff, coaches and advisors): _________

Person(s) completing this form (if different than person listed above and not anonymously reporting): ___________________

Person reporting is:		student	parent		grandparent		guardian
school staff	coach		advisor	other __________________

Contact information of person reporting (optional):
home or work phone:  (       )                             Cell phone:  (         )_________________                               
email:_______________________________________                                     
home address: __________________________________________________

Details 

Name of student(s) who is believed to have been bullied: _________________________________

Name of the student(s) or adult(s) who is alleged to have bullied: _______________

Date(s): _____________________________________________________
Time(s)/time(s) of day: ____________________________________________
Location(s) of incident(s):  _________________________________________

Were there any witnesses?   yes      no   
May the school personnel conducting an investigation contact these witnesses?
  yes      no   
If so, please provide names of witnesses to be contacted during the investigation: ____________________________________________________________
____________________________________________________________

Please provide a description of incident(s) and include any supporting documentation: 
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
(use additional pages, if needed)

I agree that the information on this form is accurate and true to the best of my knowledge and belief.

_____________________________________         	Date:  _____________ 
Signature of person reporting (optional)					

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Received by:  _________________________ 		Date:  _____________
Position/title:  _________________________	

Copy to school principal on: ______________	
					Date

Copy received: _____________________________        Date: ____________
			Signature of school principal

Copy to superintendent on: _______________
				        Date

Copy received: ______________________________        Date: ____________
Signature of superintendent