Universal Academy Online Bullying Anonymous Reporting Form

If you have information regarding bullying and would like to report this information anonymously, please fill out the following form to the best of your knowledge. Please note that this form is completely anonymous. (For the purpose of this form, bullying encompasses bullying, harassment, and discrimination.)
Victim Name*

First NameLast Name
Sex*

MaleFemale
Grade*

PreKKindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelve
Accused Name*

First NameLast Name
Sex*

MaleFemale
Grade*

PreKKindergartenFirstSecondThirdFourthFifthSixthSeventhEighthNinthTenthEleventhTwelve
School
School Phone Number

Area CodePhone Number
Administration
Today's Date

MonthDayYear
Date
Where did the incident occur?
When did the incident occur?

MonthDayYear
Date
Date

MonthDayYear
Date
Please describe, in as much detail as possible, what happened.
Do you know any of the witnesses involved? If so, please provide as much detail as possible about these people. Witnesses First/Last Name and Contact Numbers.
List evidence of bullying if any (i.e. letters, photos, etc. Attach evidence if possible)
Reporting Person's Information
Reporting Person Name

First NameLast Name
Reporting Person Email
example@example.com
Reporting Person Phone Number

Area CodePhone Number
Thank you, this report will be followed up on within 2 school/workdays. If you fear a student is in IMMEDIATE danger, contact their home school or call the police immediately!
Should be Empty: