Harassment, Intimidation & Bullying Reporting Form

Information

Name of Person Reporting Incident	You may choose to report this information anonymously. All complaints will be treated in a confidential manner. Anonymous reports may limit the district’s ability to respond to the complaint.
Phone Number
Email
Person completing this form	Student Student (witness/bystander of incident) Parent/Guardian Staff Member Community Member DASA Coordinator/Dignity Act Coordinator
Name of Target (student being bullied, harassed, or discriminated against)
Name(s) of alleged offender(s)
Date(s) of Incident(s)
What is your School? *
What was your involvement in the incident?	I was directly involved I observed the incident I heard about the incident
Where did the incident happen?	On school property Off school property At a school sponsored activity Online Other - Please fill the "Other" field bellow.
Other
Place a check next to the statement(s) that best describes what happened (choose all that apply)	Physical (including, but not limited to, kicking, punching, spitting, taking belongings) Verbal (including, but not limited to, taunting, malicious teasing, name calling, making threats) Psychological (including,but not limited to, non-verbal actions, spreading rumors, social exclusion) Electronic communications - cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures) Other - Please fill the "Other" field bellow.
Other
Who was involved in the incident?	Student Employee Both student and employee
Type of bias involved (if known): Check all that apply	Race Color Weight/size National origin Ethnic Group Religion Religious practice Disability Sexual Orientation Gender Sex Other - Please fill the "Other" field bellow.
Other
Background: Please describe what happened *
What steps, if any, have been tried to resolve the issue?
Does the situation continue to occur?	Yes No
Was the student victim absent from school as a result of the incident?	Yes No
Please provide any additional information