EmailMe Form - Report Form for Harassment, Intimidation, Bullying

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

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

Anonymous source

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 nature of alleged harassment, intimidation or bullying. Include any gesture, any relevant written verbal or physical act(s), or any electronic communication (attach additional sheets if necessary)

Location of alleged harassment, intimidation or bullying. Check and complete all that apply:

School property

Identify:

School-sponsored function

Identify function:

School bus

Identify:

Off school grounds

Describe:

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

Please add any other pertinent information

Name of person reporting

First Last

Anonymous

Anonymous (intended as an option for parent and students, not for staff members)

Today's Date

MM / DD / YYYY