Bullying Reporting Form

Bullying Reporting Form

Directions: This is a form to report alleged bullying or harassment , including cyberbullying. If you are a student target, the parent/guardian of a student target, a close adult relative of a student target, or a school staff member and wish to report an incident of alleged bullying or harassment, complete this form and return it to the Dignity Act Coordinator at the student ‘s school. Contact the school Dignity Act Coordinator for additional information or assistance at any time.

Administration will review and respond to each incident in the context of the Student Code of Conduct.

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.

*False reporting of incidents will result in disciplinary consequences.


Today's Date

Person Reporting Incident



Person Completing the Form


 Name Of Target

Name(s) of Alleged offender(s)

Date(s) of Incident

Where did the incident happen? (Choose all that apply)


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


 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?

If yes, how many days was the student victim absent from school as a result of the incident?

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