EmailMe Form

EmailMeForm

Date(s) of Alleged Incident(s) *
Check all actual or perceived characteristics that were or may have been motivational factors in the alleged bullying incident
Race
Color
Religion
Gender
Sexual Orientation
Gender Identity and Expression
Mental or Physical or Sensory Disability
Ancestry
National Origin
Other Actual or Perceived Characteristic - List Here
Indicate how you learned that a student may have been the victim of harassment, intimidation or bullying. *
Witnessed Incident
Informed by alleged victim
Annonymous
Informed by another person (identify if student, parent, staff person, other, and list here)
List any person who you know or have reason to believe may have relevant information, and indicate if student, parent, staff member or other. *
Describe the nature of alleged harassment, intimidation or bullying. Include any gesture, any relevant written verbal or physical act(s), or any electronic communication. *
Location of alleged HIB. Check all that apply and identify function below. *
Identify Function *
Identify what harm you believe was or may have been caused by the alleged incident. Check all that apply. *
Substantial disruption or interference with orderly operation of school or rights of others
Physical or emotional harm
Insulting or demeaning
Creates a hostile educational environment
Interferes with student's education
Describe in narrative form what harm you believe was caused to the student and the basis for your belief. *
Describe in narrative form what harm you believe was caused to the student and the basis for your belief. *
Please add any other pertinent information. *
Name of person reporting *
First Last
Today's Date *
MM / DD / YYYY

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