Report of Harassment / Bullying

Report of Harassment / Bullying
Student Name

First NameLast Name
Date you filled out the form:

MonthDayYear
Date
Date and time of alleged incident:

MonthDayYear
Date
Hour Minutes
Where did the incident occur?
Name of person you believe harassed/bullied you:
If the alleged harassment/bullying was toward another person, identify that other person:
Describe the incident as clearly as possible. Include a complete description of the events, verbal statements, and any physical contact:
How did you or the person harassed/bullied (if not you) react to the harassment/bullying?
List any witnesses who were present:
I hereby certify that the information I have provided in this complaint is true, correct, and complete to the best of my knowledge.
Signature of Complainant:
Should be Empty: