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:

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