Harassment, Intimidation, Hazing, and Bullying Report

Complaints regarding harassment, intimidation, hazing, and bullying can be made against students or staff members. Please include as much information as possible in making a complaint.

Your Information (optional)

Name

First Name

Last Name

Email Address

Phone #

Incident Information

When did this incident happen?

Must contain a date in MM/DD/YYYY format

Location/School where incident occurred:

Additional Location Information

Please enter more information about the location on the incident.

Your Role

Please enter any additional information about how you were involved or how you know of the incident.

Type of harassment, intimidation, hazing, bullying or harm:

Cause of harassment, intimidation, hazing, bullying or harm:

Method of harassment, intimidation, hazing, bullying or harm:

What is the victim's age/or grade?

Who was the person being harassed, intimidated, hazed, bullied or harmed?

Select the protected class the victim may fall under.

What is the name of the offender?

What is the offender's role?

If the offender is a student, what is the offender's age or grade level?

If the offender is an employee, what is the offender's title and work location?

How frequent is the harassment, intimidation, hazing, or bullying?

Has the harassment, intimidation, hazing, and bullying been reported to school or district staff before now?

Description:

Please give as much information as you can about the incident.

Does the victim fear retaliation for reporting?

By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.

By checking this box you agree to the above disclaimer.

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Harassment, Intimidation, Hazing, and Bullying Report

Harassment, Intimidation, Hazing, and Bullying Report

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