Harassment, Intimidation and Bullying Report
Your Information (Optional)
First Name:
Last Name:
E-Mail:
Phone #:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Incident Information
Please give us as much detail as you can remember
When did this incident happen?
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Building where the incident occured
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Please select school
Florence Elementary School
Florence Middle/High School
Place in the building that the incident happened.
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Unknown
Bus
Hallway
Classroom
Locker room
Gym
Cafeteria
Extracurricular activity
Bathroom
At lockers
Playground
Other
Your Role:
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Student
Teacher
Staff Member
Administrator
Parent
Volunteer
Bystander
Other
Please tell us who you are
Please enter any other information about how you were involved or how you have knowledge of teh incident.
Type of harrassment, intimidation, bullying or harm
Please enter as much information as possible about the type of bullying you are reporting
Cause of harassment, intimidation, bullying or harm:
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Unknown
Age
Color
Race
Creed
National Origin
Ancestry
Marital Status
Sex
Religion
Gender Identity
Physical Attributes
Physical/Mental Abilities
Political Belief
Political Party Preference
Socioeconomic Status
Sexual Orientation
Family Status
Other
Method of harassment, intimidation, bullying or harm:
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Unknown
Electronic Communication
Written Communication
Verbal
Physical
Social/Relational
Other
What is the victims age/or grade?:
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Who was the person being harassed, intimidated bullied or harmed?:
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What is the offenders age and/or grade?:
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Select Offender Type
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Unknown
Student from the same district
Student from a different district
Certified staff
Volunteer
Other
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Who was harassing, intimidating, bullying or causing harm?:
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Description:
Please give us as much information as you can about the incident, including any names of any witnesses and what exactly happened.
Disclaimer
By submitting this form you acknowledge that the information entered is complete, true, and accurate. Please note that whoever engages in any conduct with intent to convey false or misleading information under circumstances where such information may reasonably be relied upon and where such information indicates that an activity has taken, is taking, or will take place would constitute a violation of law and the submitter of such information may be prosecuted.
By checking this box you agree to the above disclaimer.
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Submit Incident Report
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