Bullying Harassment Complaint Form

Bullying Harassment Complaing Form

Completion of this form starts an investigation into the reported bullying or harassment. All information will be kept confidential except for details that must be disclosed to carry out the investigation. Filing a good-faith complaint will not harm the complainant’s future employment, work assignment, work environment, grades, or learning environment. By submitting this form, you affirm that the information you provide is accurate and complete to the best of your knowledge. Students may submit this report anonymously.

Privacy of Contact Information

Your name and email will not be recorded automatically when you submit this form; only provide them if you choose to. This form will not capture your personal contact details unless you enter them yourself. Your contact information is not collected by default; it will only be saved if you include it.

*Required

Please enter date:*

(MM,DD,YYYY)

Answer required for "Please enter date:"

First and last name of the student being bullied/harassed:*

Answer required for "First and last name of the student being bullied/harassed:"

School of student being bullied/harassed:*

Example: Elementary School, Middle School, High School

Answer required for "School of student being bullied/harassed:"

Please check the type of bullying that has ocurred (check all that apply):*

Answer required for "Please check the type of bullying that has ocurred (check all that apply):"

Cyberbullying (e.g, using technology to harass, threaten, or target another person - text/direct messages, email, social media, videos, etc.)

Extortion (e.g, verbal or physical buylying for money or personal time)

Hazing (e.g, having to participate in an act of physical or emotional harm to be part of a group, or are a victim of a group)

Verbal Abuse (e.g, name-calling, racial remarks, belittling, etc. done over the phone, in writing, in person)

Physical (e.g, hitting, kicking, shoving, twisting limbs, spitting, or destroying personal belongings)

Indirect Bullying (e.g., rejection, exclusion, ignoring, alienating, or isolating to purposely cause emotional distress)

Other:

Bullying harassment on the basis of:*

Answer required for "Bullying harassment on the basis of:"

Race, color, or nationality

Gender or gender identity

Disability

Other

Dates of alleged bullying or harassment:*

(MM/DD/YYYY)

Answer required for "Dates of alleged bullying or harassment:"

Individual(s) or Person(s) alleged to have committed the bullying or harassment:*

Answer required for "Individual(s) or Person(s) alleged to have committed the bullying or harassment:"

Description of the alleged incident (if possible, locations, names, use specific dates, times, etc.):*

Answer required for "Description of the alleged incident (if possible, locations, names, use specific dates, times, etc.):"

Names of witnesses:*

Answer required for "Names of witnesses:"

Have you reported this incident to anyone else:*

Answer required for "Have you reported this incident to anyone else:"

Yes

If yes, to whom did you report the incident? If no, type "N/A or n/a":*

Answer required for "If yes, to whom did you report the incident? If no, type \"N/A or n/a\":"

Please identify yourself:*

Answer required for "Please identify yourself:"

Student

Parent/Guardian

Teacher or Staff

Volunteer

Other

Name of reporting person (students may submit report anonymously):*

Answer required for "Name of reporting person (students may submit report anonymously):"

Email of reporting person ([email protected] / students may submit report anonymously):*

Never give your password to anyone.

Answer required for "Email of reporting person ([email protected] / students may submit report anonymously):"

Phone number of reporting person (XXX-XXX-XXXX / students may submit report anonymously):*

Answer required for "Phone number of reporting person (XXX-XXX-XXXX / students may submit report anonymously):"

Please fix the highlighted areas below before submitting.

Bullying Harassment Complaint Form