Bullying, Harassment, or Intimidation Reporting Form
Fill out the form carefully to report an incident to the building Principal
A separate form needs to be completed for each incident that one is reporting
School
*
Please Select
Morristown Elementary
Waldron Elementary
Morristown Jr/Sr High
Waldron Jr/Sr High
Administration Building
Person Reporting the Incident
*
First Name
Last Name
Person that will be the Primary Contact
*
First Name
Last Name
Phone Number for Contact
*
Format: (000) 000-0000.
Primary E-mail for Contact
*
example@example.com
Person Reporting the Incident
*
Please Select
Student
Parent/Guardian of a student
Close adult relative of a student
School staff
Bystander
1. Alleged Victim
*
Name
Age
2. Alleged Witness
Name
Age
Are there additional witnesses to this incident?
3. Alleged Offender
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Name
Age
Are there additional offenders that participated in this incident?
4. On what date did the incident occur?
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-
Month
-
Day
Year
Date
5. Select the statements that best describe what happened (Choose all that apply):
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Any bullying, harassment, or intimidation that involves physical aggression
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means
Demeaning and making the victim of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating (bullying), extorting, or exploiting
Spreading harmful rumors or gossip
Related to the student's disability
Related to the student's perceived sexual orientation
Cyber bullying (e.g. social media including Facebook, Twitter, Vine, Instagram, etc.)
Electronic communication (e.g. email, text, sexting, etc.)
Racial harassment
Sexual harassment
Other
For other type below:
6. Where did the incident occur (Choose all that apply):
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On school property
At a school sponsored activity or event off school property
On a school bus
On the way to or from school
Via the Internet - sent on or off school property
7. Describe the incident, including what the alleged offender said or did:
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8. Why did the bullying, harassment, or intimidation occur?
*
9. Did a physical injury result from this incident?
*
Please Select
No
Yes, but it did not require medical attention
Yes, and it required medical attention
10. Was the victim absent from school as a result of the incident?
*
Please Select
Yes
No
11. Is there any additional information that you would like to provide?
Signature
Date
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit Incident Report
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