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






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?



Where did the incident happen?





Other
Place a check next to the statement(s) that best describes what happened (choose all that apply)





Other
Who was involved in the incident?



Type of bias involved (if known): Check all that apply












Other
Background: Please describe what happened *
What steps, if any, have been tried to resolve the issue?
Does the situation continue to occur?
Was the student victim absent from school as a result of the incident?
Please provide any additional information