Report Bullying Incident

Report Bullying Incident

Please complete this form to the best of your knowledge so we can assist you.This information will be kept confidential with your campus administrator and/or superintendent.
IF THIS IS AN EMERGENCY AND YOU SUSPECT THERE IS A RISK TO SOMEONE'S LIFE, PLEASE CALL 911.
Person reporting incident - please use your full name.*

First NameLast Name
I am a:*

Dover Elementary StudentDover Middle School StudentDover High School StudentDistrict StaffParent/Guardian of Dover StudentCommunity Member
Date of incident:*

MonthDayYear
Date
Who was the person engaged in bullying?*
What is the grade of the person engaged in bullying?*
What type of bullying?*

PhysicalEmotional/SocialDamage to PropertyOnlineOther
Where did this incident take place? Be as specific as possible.*
Describe what happened with as many details as possible.*
May we contact you for more information?*

YesNo
How would you prefer to be contacted?*

EmailPhoneMeetingAny of the above
If you prefer email contact, please enter your email address.
example@example.com
If you prefer phone contact, please enter your phone number.
Please enter a valid phone number.
Should be Empty:

IF THIS IS AN EMERGENCY AND YOU SUSPECT THERE IS A RISK TO SOMEONE'S LIFE, PLEASE CALL 911.