Harassment, Intimidation & Bullying Reporting Form

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
Name of Target
Name(s) of alleged offender(s)
Date(s) of Incident(s)
What is your School? *
Where did the incident happen?	On school property Off school property At a school sponsored activity Online Other If you select Other, please fill the "Other Place" field bellow.
Other Place
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 Other If you select Other, please fill the field "Other" bellow.
Other
Background: Please describe what happened before, during and after the incident
Who else saw the incident occur?
What steps, if any, have been tried to resolve the issue?
To your knowledge, was the student victim absent from school as a result of the incident?	Yes No